Shock

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Shock

  1. 1. DEFINITION SHOCK IS A CIRCULATORY SYSTEM ABNORMALITY THAT RESULTS IN INADEQUATE OXYGEN PERFUSION AND TISSUE OXYGENATION
  2. 2. PHYSIOLOGICAL EXHAUSTION-THE TRIAD OF DEATH HYPOTHERMIA ACIDOSISCOAGULOPATHY
  3. 3.  HYPOPERFUSION STATE RESULTS IN CELLULAR ANAEROBIC METABOLISM AND LACTIC ACIDOSIS.ACIDOSIS LEADS TO DECREASED FUNCTION OF COAGULATION PROTEASES-LEADS TO COAGULOPATHY AND FURTHER HAEMORRHAGE.
  4. 4. UNDERPERFUSED MUSCLE IS UNABLE TO GENERATE HEAT AND HYPOTHERMIA OCCURS.COAGULATION FUNCTIONS POORLY AT LOW TEMPERATURE AND THERE IS FURHER HAEMORRHAGE,HYPOPERFUSION AND HYPOTHERMIA.THESE 3 FACTORS RESULT IN A DOWNWARD SPIRAL LEADIING TO PHYSIOLOGICAL EXHAUSTION AND DEATH
  5. 5. 1.HYPOVOLEMIC-HAEMORRHAGIC NON-HAEMORRHAGIC 2.CARDIOGENIC SHOCK 3.OBSTRUCTIVE 3.DISTRIBUTIVE SHOCK-ANAPHYLACTIC SEPTIC 4.ENDOCRINE SHOCK
  6. 6. STAGES OF SHOCK  COMPENSATED-- HR, Vasoconstriction, CO, normal BP  DECOMPENSATED--, HR, hypothermia, blood pressure, prolonged capillary refill time, poor peripheral pulses, and eventually urine output.  IRREVERSIBLE SHOCK
  7. 7. BLEEDING-TRAUMA,GI BLEED,RUPTURED ANEURYSM PROTRACTED VOMITING OR DIARRHEA ADRENAL INSUFFICIENCY THIRD SPACING-INTESTINAL OBSTRUCTION,PANCREATITIS
  8. 8.  HAEMORRHAGIC SHOCK-COMMONEST CAUSE OF SHOCK IN TRAUMA PATIENTS  NON-HAEMORRHAGIC CAUSES  CARDIAC PUMP PROBLEMS-CARDIAC TAMPONADE,TENSION PNEUMOTHORAX,MYOCARDIAL CONTUSION  NEUROGENIC SHOCK  SEPTIC SHOCK
  9. 9. HAEMORRHAGIC SHOCK  HAEMORRHAGE MAY BE REVEALED OR CONCEALED.  HAEMORRHAGE –EXSANGUINATION FROM OPEN ARTERIAL WOUND OR FROM HAEMETEMESIS FROM A DUODENAL ULCER  CONCEALED HAEMORRHAGE IS CONTAINED WITHIN THE BODY CAVITY.EG-WITHIN CHEST,ABDOMEN,PELVIS WITH CONTAINED VASCULAR INJURY
  10. 10. PRIMARY,SECONDARY AND REACTIONARY HAEMORRHAGE  PRIMARY HAEMORRHAGE IS HAEMORRHAGE OCCURING IMMEDIATELY AS A RESULT OF INJURY  REACTIONARY HAEMORRHAGE (WITHIN 24 HOURS) CAUSED BY DISLOGEMENT OF CLOT BY RESUSCITATION,NORMALISATION OF BP AND VASODILATATION  SECONDARY HAEMORRHAGE IS CAUSED BY SLOUGHING OF VESSEL WALL .IT USUALLY OCCURS AFTER 7-14 DAYS AFTER INJURY BY FACTORS SUCH AS INFECTION,PRESSURE NECROSIS(DRAIN)OR MALIGNANCY
  11. 11. •BLOOD LOSS IN SITE FRACTURE TIBIA/HUMERUS-750 ML BLOOD FRACTURE FEMUR-1500 ML BLOOD FRACTURE PELVIS-2 TO 3 LITRES •OBLIGATORY EDEMA IN SOFT TISSUES
  12. 12. SBP<110mm Hg Tachycardia>90/mt Tachypnea Oliguria Metabolic acidemia Hypoxemia Cutaneous vasoconstriction Mental changes-anxiety,agitation,lethargy
  13. 13. APPROPRIATE HISTORY AND CLINICAL EXAMINATION •ADJUNCTS FOR CONFIRMATION CVP CHEST/PELVIC XRAY ULTRASOUND
  14. 14. MINIMUM REQUIREMENTS MONITOR SBP,URINE OUTPUT,BP,HR,MENTAL STATE ADDITIONAL MODALITIES CVP INVASIVE BP MONITORING CARDIAC OUTPUT BASE DEFICIT SERUM LACTATE
  15. 15. CLASSIFICATION OF DEGREE OF HAEMORRHAGE
  16. 16. INITIAL MANAGEMENT OF HAEMORRHAGIC SHOCK  DIAGNOSIS AND TREATMENT IS DONE SIMULTANEOUSLY  2 BASIC PRINCIPLES ARE • STOP BLEEDING • REPLACE THE VOLUME • ANY SHOCK SHOULD BE ASSUMED HYPOVOLEMIC UNTIL PROVED OTHERWISE AND HYPOVOLEMIA SHOULD BE ASSUMED TO BE DUE TO HAEMORRHAGE UNTIL THIS HAS BEEN EXCLUDED
  17. 17. INITIAL MANAGEMENT OF HAEMORRHAGIC SHOCK  ASSESS ABCDE  BASELINE RECORDINGS-BP,PR,URINE OUTPUT,LEVEL OF CONSCIOUSNESS  CONTROL OBVIOUS HAEMORRHAGE.DIRECT PRESSURE SHOULD BE PLACED OVER SITE OF EXTERNAL HAEMORRHAGE  ADEQUATE IV ACCESS-2 LARGE BORE IV CANNULA(MINIMUM 16 GUAGE)  IF PERIPHERAL LINE NOT POSSIBLE-CENTRAL LINE,VENOUS CUT DOWN.BLOOD DRAWN FOR CROSS MATCHING  ASSESS TISSUE PERFUSION
  18. 18. INITIAL FLUID THERAPY  RINGER LACTATE IS THE FIRST CHOICE,2ND IS NORMAL SALINE  AN INTIAL BOLUS IS GIVEN AS RAPIDLY AS POSSIBLE.DOSE OF 1 -2 LITRES FOR ADULTS  20 ML/KG FOR CHILDREN.
  19. 19. DYNAMIC FLUID RESPONSE  PATIENTS CAN BE DIVIDED INTO RAPID RESPONDERS,TRANSIENT RESPONDERS AND NON RESPONDERS BASED ON RESPONSE TO FLUID THERAPY
  20. 20. RESPONSES TO INITIAL FLUID RESUSCITATIONRAPID RESPONS E TRANSIENT RESPONSE NO RESPONSE VITAL SIGNS RETURN TO NORMAL TRANSIENT IMPROVEM ENT ABNORMAL ESTIMATED BLOOD LOSS MINIMAL (10 – 20 %) MODERATE AND ONGOING (20 – 40 %) SEVERE (>40%) NEED FOR MORE CRYSTALLOID LOW MODERATE IMMEDIATE NEED FOR POSSIBLY LIKELY HIGHLY LIKELY
  21. 21.  EXCESSIVE BLOOD LOSS FROM FRACTURED BONE MAY BE PREVENTED BY AVOIDING MOVING THE PATIENT FROM ONE COUCH TO ANOTHER. .FOR FRACTURES OF PELVIS,TEMPORARY STABILISATION WITH AN EXTERNAL FIXATOR HAS BEEN FOUND TO BE USEFUL IN REDUCING HAEMORRHAGE
  22. 22. I.V. Solutions  Crystalloid  Colloid  Whole Blood or Blood Products  Water and Glucose
  23. 23. Crystalloids (Isotonic)  Solutions of ions with an osmolarity similar to that of plasma.  Effective, short term, volume replacement  Do NOT have O2 carrying capacity  Do NOT contain protein
  24. 24. Crystalloids (Isotonic)  Most common crystalloids  Normal saline  Fluid of choice in combat  Ringers lactate  Most physiologically adaptable solution available  Hartmann,s solution
  25. 25. Crystalloids (Isotonic)  Precautions  Always consider fluid volume overload  Excessive infusion of electrolytes may cause electrolyte imbalances  DO NOT use in patient’s with  Cardiac failure  Liver disease  0.9% NaCl is C/I in metabolic axidosis as it is an acidifying solution, which may slow down the resolution of the metabolic acidosis, so in that case use RL
  26. 26. C OLLOIDS  are large molecules that cannot freely diffuse through the capillary membrane  NO oxygen carrying capacity  ALBUMIN  HETASTARCH – SYNTHETIC  The advantage of colloids is that since they do not rapidly diffuse across the capillary membrane, they act to hold water in the intravascular space and maintain intravascular volume expansion for longer periods of time than crystalloids
  27. 27. Water and Glucose  These solutions are Hypotonic  Most common concentrations:  D5W – Fluid replacement and caloric supplementation  D50W – treats hypoglycemic (low blood sugar) in adults
  28. 28. Water and Glucose  Contraindications:  DO NOT use in HEAD INJURIES  Will cause cellular swelling  Precautions:  Volume overload  Electrolyte imbalance
  29. 29. Whole Blood  Ideal replacement fluid if blood is being lost  Indications  Acute massive blood loss  Will resolve symptoms of hypovolemic shock and anemia
  30. 30. VASSOPRESSOR AND IONOTROPICS  NOT AS FIRST LINE THERAPY  Administration of this agents in absence of adequqte preload lead to decrease coronary perfusion and depletion of myocardial oxygen reserve  Noradrenaline – distributive shock  Ionotrops in - cardiogenic shock
  31. 31. SEPTIC SHOCK  Severe sepsis with cardiovascular organ dysfunction, i.e. hypotension (systolic blood pressure [SBP] < 5th centile  non-specific systemic inflammatory response to infection,trauma, burns, surgery etc.  Characterized by abnormalities in 2 or more of the following • body temperature• heart rate• respiratory function • peripheral leucocyte count
  32. 32. SEPTIC SHOCK --management  RESUSCITATION– ABC  FLUID THERAPY-- aggressive fluid resuscitation with crystalloids or colloids at 20 mls/kg as rapid IVpush over 5-10 mins. Can be repeated up to 60 mls/kg or more.  - correct hypoglycaemia and hypocalcaemia  IONOTROPES -- IV Dopamine 5 - 15 μg/kg min  IV Dobutamine 5 - 15 μg/kg/min  - for fluid refractory and dopamine/dobutamine refractory shock Adrenaline is given
  33. 33.  ANTIMICROBIAL-- IV antibiotics should be administered immediately after appropriate cultures are taken.  Start empirical, broad spectrum to cover all likely pathogens  antibiotic regime to be modified accordingly once C&S results
  34. 34.  RESPIRATORY SUPPORT- use PEEP and FIO2 to keep SaO2 > 90%, PaO2 > 80 mmHg  SUPPORTIVE THERAPY-  packed cells transfusion if Hb <10g%  - platelet concentrate transfusion if platelet count < 20 000  - if overt clinical bleeding, correct coagulopathy or DIVC
  35. 35.  - bicarbonate therapy: give bicarbonate only in refractory metabolic acidosis,  - maintain normal electrolytes and blood sugar
  36. 36. THANK YOU

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