SHOCK James Taclin C. Banez, M.D.
<ul><li>Definition: </li></ul><ul><ul><li>Conditions that lowers tissue perfusion </li></ul></ul><ul><ul><ul><li>decrease ...
<ul><li>TYPE: </li></ul><ul><li>Hypovolemic Shock: </li></ul><ul><ul><li>low pre-load </li></ul></ul><ul><ul><li>low syste...
<ul><li>Traumatic Shock: </li></ul><ul><ul><li>hypovolemia </li></ul></ul><ul><ul><li>toxic factors (cytokines) from injur...
<ul><li>Cardiac Compressive Shock: </li></ul><ul><ul><li>has a normal heart </li></ul></ul><ul><ul><li>low cardiac return ...
<ul><li>Cellular Changes: </li></ul><ul><ul><li>decrease tissue perfusion ----> decrease oxygen delivery ----> decrease AT...
<ul><li>Renal Response: </li></ul><ul><ul><li>Normal kidneys can tolerate renal ischemia from 15 mins to a maximum of 90 m...
Pulmonary Response: <ul><ul><li>Damage Alveolar – Capillary interface  in case of shock ----> acute diffuse lung injury. <...
Pathophysiology <ul><li>Hypovolemic Shock: </li></ul><ul><ul><li>most common </li></ul></ul><ul><ul><li>Most of the blood ...
Degree of Hemorrhagic Shock <ul><li>Mild Hemorrhagic Shock: </li></ul><ul><ul><li>< 20% blood lost </li></ul></ul><ul><ul>...
Degree of Hemorrhagic Shock <ul><li>Moderate Hemorrhagic Shock: </li></ul><ul><ul><li>20 – 40% blood loss </li></ul></ul><...
Degree of Hemorrhagic Shock <ul><li>Severe Hemorrhagic Shock: </li></ul><ul><ul><li>40% blood lost </li></ul></ul><ul><ul>...
Compensatory Mechanism <ul><li>Adrenergic discharge </li></ul><ul><li>Hyperventilation: </li></ul><ul><ul><li>with spontan...
Compensatory Mechanism <ul><li>Release of fluid from the interstitium into the vascular space: </li></ul><ul><ul><li>Epine...
Compensatory Mechanism <ul><li>Release of vasoactive hormones: </li></ul><ul><li>Resorption of fluid from intracellular to...
Compensatory Mechanism <ul><li>Renal conservation of body H2O and electrolyte </li></ul><ul><ul><li>aldosterone </li></ul>...
Decompensation in Hypovolemic Shock <ul><li>Relaxation of arteriolar and precapillary spasm </li></ul><ul><ul><li>forced H...
<ul><li>Two Most Sensitive Signs of Hypovolemia are: </li></ul><ul><li>Cutaneous vasoconstriction </li></ul><ul><li>Oligur...
<ul><li>Monitoring: </li></ul><ul><li>Management: </li></ul><ul><ul><li>resuscitate patient and control blood lost and cor...
<ul><li>Management: </li></ul><ul><ul><li>Supine position w/ elevated both lower   extremities :    preferred position fo...
<ul><li>Causes of Refractory Shock: </li></ul><ul><ul><li>Continuing blood loss from primary injury or another source </li...
Traumatic Shock <ul><li>Traumatized tissue activates coagulation system forming: </li></ul><ul><ul><li>Microthrombi: </li>...
Traumatic Shock <ul><li>Treatment: </li></ul><ul><ul><li>Primary treatment is correct hypovolemia </li></ul></ul><ul><ul><...
Cardiogenic Shock <ul><li>s/sx of myocardial ischemia </li></ul><ul><li>Increase CVP and pulmonary artery wedge pressure w...
Cardiac Compressive Shock <ul><li>Pericardial tamponade: </li></ul><ul><ul><li>there is decrease pericardial compliance on...
Cardiac Compressive Shock <ul><li>Sign/Symptoms: </li></ul><ul><ul><li>Distended neck veins </li></ul></ul><ul><ul><li>Muf...
Cardiac Compressive Shock <ul><li>Chest X-ray: </li></ul><ul><ul><li>Water bottle shape (erect film) </li></ul></ul><ul><l...
Septic Shock <ul><li>Causes: </li></ul><ul><li>Gram positive sepsis (exotoxin) </li></ul><ul><li>Gram negative sepsis (end...
Septic Shock <ul><li>Early septic shock: </li></ul><ul><ul><li>warm extremity, pt is still normovolemic </li></ul></ul><ul...
Septic Shock <ul><li>Late septic shock: </li></ul><ul><ul><li>cold extremity, patient is hypovolemic </li></ul></ul><ul><u...
Septic Shock <ul><li>Treatment: </li></ul><ul><ul><li>volume replacement </li></ul></ul><ul><ul><li>look for the source of...
Neurogenic Shock <ul><li>Seen in spinal cord injuries and spinal anesthesia. </li></ul><ul><li>normovolemic / hypovolemic ...
Neurogenic Shock <ul><li>hypervolemic pt.: </li></ul><ul><ul><li>cardiac output increase due to expanded blood volume and ...
THANK YOU
Upcoming SlideShare
Loading in …5
×

Shock 090914002728 Phpapp02

2,579 views

Published on

Published in: Health & Medicine, Business
0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,579
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
125
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide

Shock 090914002728 Phpapp02

  1. 1. SHOCK James Taclin C. Banez, M.D.
  2. 2. <ul><li>Definition: </li></ul><ul><ul><li>Conditions that lowers tissue perfusion </li></ul></ul><ul><ul><ul><li>decrease tonicity of blood vessel wall </li></ul></ul></ul><ul><ul><ul><ul><li>neurogenic shock </li></ul></ul></ul></ul><ul><ul><ul><ul><li>early septic shock </li></ul></ul></ul></ul><ul><ul><ul><ul><li>anaphylactic shock </li></ul></ul></ul></ul><ul><ul><ul><li>decrease blood volume </li></ul></ul></ul><ul><ul><ul><ul><li>hypovolemic shock (hemorrhagic shock) </li></ul></ul></ul></ul><ul><ul><ul><li>decrease cardiac output due to myocardial failure. </li></ul></ul></ul><ul><ul><ul><ul><li>myocardial ischemia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>cardiac compressive shock (pericardial tamponade) </li></ul></ul></ul></ul>
  3. 3. <ul><li>TYPE: </li></ul><ul><li>Hypovolemic Shock: </li></ul><ul><ul><li>low pre-load </li></ul></ul><ul><ul><li>low systemic arterial pressure </li></ul></ul><ul><ul><li>tachycardia </li></ul></ul><ul><ul><li>increase vascular resistance </li></ul></ul>
  4. 4. <ul><li>Traumatic Shock: </li></ul><ul><ul><li>hypovolemia </li></ul></ul><ul><ul><li>toxic factors (cytokines) from injured tissues enters to the blood ----> activates intravascular inflammation & intravascular coagulation. (increase vascular permeability ---> multiple organ failure). </li></ul></ul><ul><li>Cardiogenic Shock: </li></ul><ul><ul><li>heart failure </li></ul></ul><ul><ul><li>blood clogged behind the heart </li></ul></ul><ul><ul><li>increase filling pressure </li></ul></ul>
  5. 5. <ul><li>Cardiac Compressive Shock: </li></ul><ul><ul><li>has a normal heart </li></ul></ul><ul><ul><li>low cardiac return due to extrinsic compression </li></ul></ul><ul><ul><li>pericardial tamponade </li></ul></ul><ul><li>Septic Shock </li></ul><ul><ul><li>systemic changes brought by bacterial toxins </li></ul></ul><ul><li>Neurogenic Shock </li></ul><ul><ul><li>loss of arterial and venous tone </li></ul></ul><ul><ul><li>pool of blood in dilated peripheral venous system </li></ul></ul>
  6. 6. <ul><li>Cellular Changes: </li></ul><ul><ul><li>decrease tissue perfusion ----> decrease oxygen delivery ----> decrease ATP -----> Na/K membrane pump fails ----> Na & Cl enters the cell ---> isotonic cellular swelling ----> cell death. </li></ul></ul>
  7. 7. <ul><li>Renal Response: </li></ul><ul><ul><li>Normal kidneys can tolerate renal ischemia from 15 mins to a maximum of 90 mins. Can be prolonged w/ hypothermia and/or steroid) </li></ul></ul><ul><ul><li>Prolonged hypoperfusion leads to functional and anatomic changes presenting as azotemia. </li></ul></ul><ul><ul><li>Renal failure index : </li></ul></ul><ul><ul><ul><li>( Urine Na x Plasma creatinine ) </li></ul></ul></ul><ul><ul><ul><li>Urine creatinine </li></ul></ul></ul><ul><ul><ul><li>< 1 usually indicates pre-renal oliguria </li></ul></ul></ul><ul><ul><ul><li>> 1 indicates acute renal failure </li></ul></ul></ul>
  8. 8. Pulmonary Response: <ul><ul><li>Damage Alveolar – Capillary interface in case of shock ----> acute diffuse lung injury. </li></ul></ul><ul><ul><li>Leakage of proteinaceous fluid into the interstitium and alveolar space. </li></ul></ul><ul><ul><li>Leads to ARDS : </li></ul></ul><ul><ul><ul><li>Hypoxemia unresponsive to elevation of FiO2 </li></ul></ul></ul><ul><ul><ul><li>Decreased pulmonary compliance </li></ul></ul></ul><ul><ul><ul><li>Needs high airway pressure to attain adequate tidal volume </li></ul></ul></ul>
  9. 9. Pathophysiology <ul><li>Hypovolemic Shock: </li></ul><ul><ul><li>most common </li></ul></ul><ul><ul><li>Most of the blood is lost from systemic and small veins (50%) ----> decrease cardiac return ----> low cardiac output ----> decrease blood pressure </li></ul></ul>
  10. 10. Degree of Hemorrhagic Shock <ul><li>Mild Hemorrhagic Shock: </li></ul><ul><ul><li>< 20% blood lost </li></ul></ul><ul><ul><li>adrenergic constriction of blood vessels in the skin </li></ul></ul><ul><ul><li>thirsty, feels cold </li></ul></ul><ul><ul><li>normal BP, PR and urine output </li></ul></ul>
  11. 11. Degree of Hemorrhagic Shock <ul><li>Moderate Hemorrhagic Shock: </li></ul><ul><ul><li>20 – 40% blood loss </li></ul></ul><ul><ul><li>(+) above signs and symptoms </li></ul></ul><ul><ul><li>low urine output </li></ul></ul><ul><ul><ul><li>Due to aldosteron and ADH </li></ul></ul></ul>
  12. 12. Degree of Hemorrhagic Shock <ul><li>Severe Hemorrhagic Shock: </li></ul><ul><ul><li>40% blood lost </li></ul></ul><ul><ul><li>In addition to above s/sx pt has low BP and rapid pulse rate </li></ul></ul><ul><ul><li>signs of M.I. ---> Q waves and depressed </li></ul></ul><ul><ul><li>St-T segments </li></ul></ul>
  13. 13. Compensatory Mechanism <ul><li>Adrenergic discharge </li></ul><ul><li>Hyperventilation: </li></ul><ul><ul><li>with spontaneous deep breathing there is a decreased intra-thoracic ----> increase ventricular end diastolic volume ----> increase cardiac output. </li></ul></ul><ul><li>Collapse: </li></ul><ul><ul><li>Displaced blood from extremity to the heart and the brain </li></ul></ul>
  14. 14. Compensatory Mechanism <ul><li>Release of fluid from the interstitium into the vascular space: </li></ul><ul><ul><li>Epinephrine causes constriction of the arterioles and precapillary sphincter ----> decrease intracapillary hydrostatic pressure ----> influx of H2O, Na & Cl </li></ul></ul>
  15. 15. Compensatory Mechanism <ul><li>Release of vasoactive hormones: </li></ul><ul><li>Resorption of fluid from intracellular to extracellular space: </li></ul><ul><ul><li>Epinephrine, cortisol and glucagon increases concentration of interstitial glucose ----> extracellular hyperosmolality ----> draws H2O from cell ----> hydrostatic pressure in the interstitium ----> forced H2O and CHON into the lymphatics -------------> oncotic pressure intravascular ----> attracts H2O intravascularly further </li></ul></ul>
  16. 16. Compensatory Mechanism <ul><li>Renal conservation of body H2O and electrolyte </li></ul><ul><ul><li>aldosterone </li></ul></ul><ul><ul><li>anti-diuretic hormone (vasopressin) </li></ul></ul>
  17. 17. Decompensation in Hypovolemic Shock <ul><li>Relaxation of arteriolar and precapillary spasm </li></ul><ul><ul><li>forced H20 and electrolyte from vascular space into the interstitium </li></ul></ul><ul><li>Deterioration of cell membrane function </li></ul>
  18. 18. <ul><li>Two Most Sensitive Signs of Hypovolemia are: </li></ul><ul><li>Cutaneous vasoconstriction </li></ul><ul><li>Oliguria </li></ul><ul><li>Alcohol can cause vasodilation and inhibits secretion of ADH </li></ul>
  19. 19. <ul><li>Monitoring: </li></ul><ul><li>Management: </li></ul><ul><ul><li>resuscitate patient and control blood lost and correct dehydration </li></ul></ul><ul><ul><li>give balance salt solution (crytalloid) </li></ul></ul><ul><ul><li>disadvantage of giving colloid resuscitation. </li></ul></ul><ul><ul><ul><li>Post-resuscitation HPN </li></ul></ul></ul><ul><ul><ul><li>Increase intravascular volume at the expense of necessary interstitial fluid </li></ul></ul></ul><ul><ul><ul><li>Depression of albumin synthesis </li></ul></ul></ul><ul><ul><ul><li>Depression of circulating immunoglobulin </li></ul></ul></ul><ul><ul><ul><li>More expensive and less easier to titrate </li></ul></ul></ul>
  20. 20. <ul><li>Management: </li></ul><ul><ul><li>Supine position w/ elevated both lower extremities :  preferred position for patient in shock </li></ul></ul><ul><ul><li>Elderly patient ---> check condition of the heart (digitalis) ability to compensate. </li></ul></ul><ul><ul><li>Steroid is not indicated </li></ul></ul><ul><ul><li>O2 inhalation is of little value if vascular volume is not corrected </li></ul></ul>
  21. 21. <ul><li>Causes of Refractory Shock: </li></ul><ul><ul><li>Continuing blood loss from primary injury or another source </li></ul></ul><ul><ul><li>Inadequate replacement of fluids </li></ul></ul><ul><ul><li>Massive trauma or other derangement </li></ul></ul><ul><ul><li>Myocardial infarction </li></ul></ul><ul><ul><li>Concomitant septic shock </li></ul></ul>
  22. 22. Traumatic Shock <ul><li>Traumatized tissue activates coagulation system forming: </li></ul><ul><ul><li>Microthrombi: </li></ul></ul><ul><ul><ul><li>Occludes pulmonary vasculature ---> increase pulmonary vascular resistance ----> increase right arterial pressure </li></ul></ul></ul><ul><ul><li>Humoral products of microthrombi : </li></ul></ul><ul><ul><ul><li>cytoxines </li></ul></ul></ul><ul><ul><ul><li>Increases vascular permeability ---> loss of plasma </li></ul></ul></ul>
  23. 23. Traumatic Shock <ul><li>Treatment: </li></ul><ul><ul><li>Primary treatment is correct hypovolemia </li></ul></ul><ul><ul><li>Debridement of ischemic or dead tissue </li></ul></ul><ul><ul><li>If necessary connect to a mechanical ventilatory support </li></ul></ul>
  24. 24. Cardiogenic Shock <ul><li>s/sx of myocardial ischemia </li></ul><ul><li>Increase CVP and pulmonary artery wedge pressure w/ decrease C.O. and fails to respond with fluid solution. </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>Bed rest, O2 inhalation, narcotic analgesic </li></ul></ul><ul><ul><li>Monitoring of cardiac function </li></ul></ul><ul><ul><li>Medications: digitalis / dopamine / ganglionic blocking agents / lidocaine </li></ul></ul><ul><ul><li>Low cardiac output secondary to low heart rate ---> cardiac pacemaker </li></ul></ul>
  25. 25. Cardiac Compressive Shock <ul><li>Pericardial tamponade: </li></ul><ul><ul><li>there is decrease pericardial compliance on right atrium, right ventricle and left atrium --------> decrease cardiac output associated with high filling pressure and small chamber volumes. </li></ul></ul>
  26. 26. Cardiac Compressive Shock <ul><li>Sign/Symptoms: </li></ul><ul><ul><li>Distended neck veins </li></ul></ul><ul><ul><li>Muffled heart sound </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Pulsus paradoxicus </li></ul></ul><ul><ul><li>Oliguria </li></ul></ul><ul><ul><li>Cold clammy skin </li></ul></ul>
  27. 27. Cardiac Compressive Shock <ul><li>Chest X-ray: </li></ul><ul><ul><li>Water bottle shape (erect film) </li></ul></ul><ul><li>Management: </li></ul><ul><ul><li>in unstable pt . – do anterolateral thoracotomy w/ decompression of the tamponade and surgical control of the abnormality </li></ul></ul><ul><ul><li>In stable pt. – do pericardiocentesis, withdrawal of 50cc. Blood shd. Return cardiovascular dynamics to normal </li></ul></ul>
  28. 28. Septic Shock <ul><li>Causes: </li></ul><ul><li>Gram positive sepsis (exotoxin) </li></ul><ul><li>Gram negative sepsis (endotoxin) </li></ul><ul><ul><li>More common </li></ul></ul><ul><ul><li>Source of infection: </li></ul></ul><ul><ul><ul><li>genito-urinary </li></ul></ul></ul><ul><ul><ul><li>respiratory </li></ul></ul></ul><ul><ul><ul><li>alimentary </li></ul></ul></ul><ul><ul><ul><li>integumentary </li></ul></ul></ul>
  29. 29. Septic Shock <ul><li>Early septic shock: </li></ul><ul><ul><li>warm extremity, pt is still normovolemic </li></ul></ul><ul><ul><li>toxin increases core body temperature </li></ul></ul><ul><ul><li>BP decreases due to vasodilatation (decrease peripheral resistance) </li></ul></ul><ul><ul><li>increase cardiac output due to minimal resistance </li></ul></ul><ul><ul><li>increase heart rate and increase cardiac contractility </li></ul></ul><ul><ul><li>hyperventilation ----> respiratory alkalosis </li></ul></ul>
  30. 30. Septic Shock <ul><li>Late septic shock: </li></ul><ul><ul><li>cold extremity, patient is hypovolemic </li></ul></ul><ul><ul><li>hypovolemia due to --> increase vascular permeability and decrease cardiac output </li></ul></ul><ul><ul><ul><li>Increase vascular permeability (endotoxin) </li></ul></ul></ul><ul><ul><ul><li>Decrease cardiac output  due to increased pulmonary vascular resistance (endotoxin) </li></ul></ul></ul><ul><ul><ul><li>Increase right ventricular pressure --> due to impairment of emptying. </li></ul></ul></ul><ul><ul><li>Increase peripheral resistance (cold cyanotic extremities) </li></ul></ul><ul><ul><li>Decrease CVP </li></ul></ul>
  31. 31. Septic Shock <ul><li>Treatment: </li></ul><ul><ul><li>volume replacement </li></ul></ul><ul><ul><li>look for the source of infection to give the proper antibiotic (culture and sensitivity) </li></ul></ul><ul><ul><li>Earliest sign of gm(-) infection: </li></ul></ul><ul><ul><ul><li>hyperventilation </li></ul></ul></ul><ul><ul><ul><li>respiratory alkalosis </li></ul></ul></ul><ul><ul><ul><li>altered sensorium </li></ul></ul></ul>
  32. 32. Neurogenic Shock <ul><li>Seen in spinal cord injuries and spinal anesthesia. </li></ul><ul><li>normovolemic / hypovolemic pt.: </li></ul><ul><ul><li>Blood pool in the systemic venules and small veins resulting to decrease right heart filling ----> decrease stroke volume ----> decrease cardiac output ----> (+) angiotensin and ADH </li></ul></ul>
  33. 33. Neurogenic Shock <ul><li>hypervolemic pt.: </li></ul><ul><ul><li>cardiac output increase due to expanded blood volume and decrease vascular resistance. </li></ul></ul><ul><ul><li>hypotension due to decrease vascular resistance </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Give IVF, if BP does not respond ----> give vasoconstrictor to restore venous tone ----> restore right cardiac filling ----> increase cardiac output. </li></ul></ul><ul><ul><li>Elevate the lower extremities </li></ul></ul>
  34. 34. THANK YOU

×