presentation for medical students

1. Definition:
Shock is an acute circulatory failure with a
violation of macro- and
microhemodynamics, the inability of the
cardiovascular system to provide adequate
blood circulation to organs and tissues, their
hypoperfusion, and accumulation.
underoxidized products with the development
multiple organ failure syndrome
and death.

2.  Shock is a critical condition that
develops due to tissue hypoperfusion
as a result of acute circulatory failure.

3. Syndromescharacterizing shock :
 - hypovolemia
 - centralization of blood circulation
 - multiple organ failure (MOF)
 - violation of the rheological properties of blood
 - coagulopathy:
 1) DIC syndrome
 2) thrombohemorrhagic syndrome;
 - sequestration of blood in the capillaries;
 - generalized proteolysis

4. Pathogenesis:
The main pathogenetic element of shock is
generalized tissue hypoperfusion
disrupts homeostatic mechanisms and
leads to irreversible cellular damage.
The essence of shock is tissue hypoperfusion,
which leads to cell ischemia with a transition to
anaerobic metabolic pathway with development
lactic acidosis and multiple organ failure.

5. Minimum pathophysiology:
Circulation is determined by three main
factors:
-VCB (volume of circulating blood)
-TPVR (total peripheral vascular resistance)
-PFH (pumping function of the heart)

6. Reasons for shock:
- decrease in VCB( hypovolemic )
- deposit blood in venous pool
( distributing )
- small cordial release ( cardiogenic ).

7. Hypovolemic:
- Decreased total blood volume and ( hypovole-
mimic shock ) due to bleeding, dehydration
(vomiting, diarrhea), polyuria, burns.
The main pathogenetic mechanism is
insufficiency
of cardiac preload due to venous return
deficiency.

8. Distributor:
Deposition of blood in venous pools (distributing,
distributive, vasogenic)
with anaphylaxis, acute adrenal
statism, sepsis, neurogenic mechanism (spinal cord
injury, poisoning with vascular depressive
toxicants, iatrogenic "high spinal block").
The leading pathogenetic mechanism is lack of
cardiac afterload.

9. Cardiogenic shock:
Low cardiac output (cardiogenic shock)
due to insufficiency of the pumping function of the
heart, as well as due to:
 obstruction of venous flow to the heart
or
 insufficiency of cardiac output (obstructive shock)
in diseases of the pericardium, tension
pneumothorax.

10. Classification of types of shock:
1. Hypovolemic ( hemorrhagic , traumatic ).
2.Distributing( distributive ):
- anaphylactic ;
- neurogenic ;
3. Cardiogenic ( hemodynamically unstable arrhythmias ,
cardiomyopathy , congenital heart disease ,
injury hearts ). Obstructive shock : obstruction of venous
flow to the heart or cardiac ejection in diseases of the
pericardium, tension pneumothorax ).
4.Septic .

11. Shock stages:
1. Reverse shock.
2. Irreversible shock.

12. Mortality
Lethality at
 cardiogenic shock 30-90%
 septic in 80-90%
 hypovolemic 75-90%
 anaphylactic 10-30%
( of which up to 70% die from
respiratory disorders and others
from cardiovascular causes )

13. Delivery protocol medical care for
anaphylactic shock
Anaphylactic shock - this is an allergic
reaction of an immediate type,
accompanied by life-threatening clinical
manifestations (a sharp decrease in blood
pressure, impaired activity of the central
and peripheral nervous systems, endocrine
disorders, respiratory failure).

14. Clinical manifestations of anaphylactic shock
 - violation of hemodynamics;
 - respiratory failure (shortness of breath,
suffocation, bronchospasm);
 - violation of the gastrointestinal tract
(nausea, vomiting, diarrhea);
 - skin rash (urticaria, other exanthems,
Quincke's edema);

15. Forms of drug-induced anaphylactic shock:
- Standard form;
- hemodynamic variant;
- Asphyctic variant;
- Cerebral variant;
- Abdominal option.

16. Adrenaline is a direct histamine bioantagonist
 A 0.1% solution of adrenaline is injected
subcutaneously at a dose of 0.1 - 0.5 ml (if
necessary, repeat the injection after 20-40
minutes under the control of blood pressure).
With unstable hemodynamics, with an immediate
threat to life, it is possible to / in the introduction
of adrenaline. In this case, 1 ml of a 0.1%
solution of adrenaline is dissolved in 100 ml of
isotonic sodium chloride solution and injected at
an initial rate of 10 µg / min (1 ml / min ).

17. Anaphylactic shock: IT "second line"
- Sympathomimetics :
- norepinephrine ( norepinephrine ): 0.05-0.3
mcg / kg / min . (1amp - 1ml - 1mg)
- Dopamine : 5mcg/kg/ min .
- Glucocorticoids :
- prednisolone up to 1000 mg daily

18. Anaphylactic shock: IT "second line"
- Oxygen therapy (if necessary, mechanical
ventilation)
- Crystoloids , colloids in / in
- Sympathomatic therapy
- Inhibitors proton pumps
- Inhibitors proteolysis

19. Hypovolemic shock: directions of IT
- elimination of the cause: stop bleeding
- aggressive liquidation VCB deficiency (plasma
mosquitoes and plasma expanders ; crystal -
loids and colloids ( gelatin preparations,
dextrans ). According to indications can enter drugs
blood .
When saving peripheral vasospasm with restored
VCB is acceptable application vasodilators (
droperidol 2.5-5 mg or chlorpromazine 25-50 mg).

20. Infusion parameters:
Infusion into 3-4 veins (of which one is central).
With hemorrhagic shock 150-250 ml / min.
With substabilization of blood pressure - 100-50 ml /
min.
-High infusion rate
- "Warm" solutions
-control of CVP, diuresis
- oxygen therapy.

21. Vasofix
color coding Diameter, G Dimensions,
mm
Flow, ml/min
Orange fourteen 2.1x50 343
Grey 16 1.7x50 196
White 17 1.5x45 128
Green eighteen
eighteen
1.3 x45
1.3x33 _
96
103
Pink twenty
twenty
1.3x33
1.1x25 _
61
65
Blue 22 0.9x25 3 6
Yellow 24 0.7x19 2 2

22. Cardiogenic shock: directions of IT
1. Eliminate the cause (ex . arrhythmias )
2. Zoom contractility myocardium :
Cardiotonic preparations :
Dobutamine - 2.5-12 mcg / kg / min ( agonist of ß 1-, ß 2-, à - adrenoreceptors
).
Dopamine : 5-10 mcg/kg/ min .
Vasopressors :
Norepinephrine : 0.1-0.3 mcg/kg/ min .
Phenylephrine ( mezaton ): 1 mcg / kg ( side ) action - bradycardia ,
hypoperfusion kidneys ).

23. Cardiogenic shock: directions of IT
 3. Improvement of tissue perfusion - with the help of peripheral
vasodilators - is mandatory against the background of
restoration of myocardial contractility . The most suitable drug
is nitroglycerin (0.5 - 0.8 µg/kg/min).
 4. Correction of inevitable hypovolemia (against the
background of a compromised myocardium - at a low rate of 2-
2.5 l / min). It is better to inject concentrated solutions with a
small amount of free water: glucose 20-30% with insulin and K
+, reopoliglyukin, albumin, plasma - to restore bcc and improve
the rheological properties of blood.

24. Cardiogenic shock: directions of IT
 5. Prevention and treatment violations in the RASK system. For
a warning microthrombosis heparin 5000 IU every 3-4 hours is
used . in / in ( under the control of the L and -White method).
 Low molecular weight fractionated heparins (fraxiparin,
clexane) at a dose of 0.3 - 0.6 ml 1-2 times a day under skin of
the abdomen.
 Inhibitors proteolysis : contrykal 100,000 - 500,000 units per
day.

25. Cardiogenic shock: directions of IT
 Cell membrane stabilizers - glucocorticosteroid:
prednisolone 30-60 mg 4-6 times a day.
 Antiarrhythmic drugs:
 - atrial arrhythmias (AF, PST): vagotonic techniques - carotid sinus
massage, Valsalva maneuver, calcium channel blockers (verapamil
5-10 mg IV every 15-20 minutes), β-blockers, digoxin,
cardioversion.
 - sinus and AV bradycardia: atropine 0.5-1 mg every 5 minutes (up
to a total dose of 2 mg).
 - ventricular arrhythmias: lidocaine 1-2 mg/kg. After the restoration
of the rhythm, the infusion is continued at a rate of 30-60 mg / kg /
min.
 Amiodarone is effective in supraventricular and ventricular
disorders. The dose depends on the clinical situation.

26. Septic shock
Sepsis with arterial hypotension against the background
of adequate fluid therapy with signs of tissue
hypoperfusion, the hallmark of which is that the
deterioration of cellular metabolism precedes
circulatory failure, and not vice versa.

27. Septic shock has traits all types of shock, since sepsis itself
leads to polyorganism. insufficiency (PON), however his
received classify _ _ distribution shocks , since one of the links
in septic shock is an increase under action microbial toxins
volume of arterio-venular shunt and in , this leads to
tissue hypoperfusion

28. Pathophysiology:
 Myocardial dysfunction
 Venodilatation .
From a clinical point of view , these processes
appear in the form systemic
incendiary answers .

29.  Multiple organ failure (MOF) as the main septic
shock syndrome is the result of acute damage to
organs and systems by mediators of a critical
state, when the body cannot maintain
homeostasis.

30. Mechanisms of multiple organ failure syndrome (MOF) in
sepsis:
 - mediator - autoimmune damage;
 - microcirculatory-reperfusion syndrome;
 - infectious-septic (the idea of the intestine as
 about not drained abscess);
 double whammy phenomenon . It has two development paths:
 1) primary MOF - the result of any damaging factor (polytrauma,
severe burns, poisoning with toxic substances);
2) secondary MOF - the result of an excessive generalized response of
the body to a damaging factor and manifested after a latent period.

31. The clinical diagnosis of septic shock is made when:
acute circulatory failure with
persistent arterial hypotension
- BP syst. <90 mmHg;
- SBP less than the initial one by 40 mm Hg. and more
in the absence of other apparent causes of hypotension
and
despite adequate replenishment of the VCB deficit.

32. Because septic shock is a condition that includes
has two clinical syndromes - sepsis and shock , it is necessary highlight
characteristic signs of sepsis infections and systemic incendiary answers :
1) Clinical signs :
- body temperature above 38.8° or below 36°;
- Heart rate > 90 bpm ;
- tachypne ;
- violation consciousness ;
- reliable edema or positive more water balance
20 ml/kg/ day within 24 hours or longer ;
- glycemia more than 7.7 mmol / l in the absence diabetes .

33. 2) Manifestations of inflammation:
- leukocytosis more than 12 thousand or leukopenia less than 4
thousand;
- normal content leukocytes in the amount young forms
more than 10%;
-C- reactive plasma protein _ above norms ;
- procalcitonin above norms .

34. 3) Hemodynamic parameters:
- ATsist . < 90 mmHg , mean BP (SBP) < 70 mm Hg ;
Average BP formula :
ABP = BP diast . + ( AT system - AD diast . ) / 3

35. 4) Signs of organ dysfunction:
- hypoxemia ;
- acute oliguria ( less than 0.5 ml/kg/h);
- concentration creatinine more than 120 µmol / l;
- intestinal paresis;
- thrombocytopenia (less than 100 thousand);
- general bilirubin more than 70 µmol / l

36. 5) Indicators of tissue perfusion:
- hyperlactatemia more than 1 mmol/l;
- decrease in capillary filling (syndrome of white
spots)

37. Hyperdynamic septic shock
("hot shock")
- Fever, tachycardia, tachypnea, warm skin.
-high systAp with simultaneous deficiency of
diastAp
- Ringing heart sounds
-sufficient diuresis
-High or normal arteriovenous O2 difference

38. Decompensated septic shock
(cold shock)
 Decreased diuresis
 Silent heart sounds
 Elongated white spot symptom
 Marbling and pallor of the skin
 Arterial hypotension
 Low arteriovenous O2 difference
 hypoxemia
 Metabolic lactic acidosis.

39. Treatment of patients with severe septic shock:
Urgent measures must be carried out immediatelyif a diagnosis of "septic
shock" is established , this is evidenced by:
- arterial hypotension persists for a long time against the background of
adequate infusion therapy;
- tissue hypoperfusion (lactate not less than 4 mmol/l)

40.  Targets to be achieved in the first 6 hours intensive care
for septic shock:
- CVP 110-160 mm water column;
- SBP ≥ 65 mm Hg;
- diuresis ≥ 0.5 ml/kg/h;
- SvO2 >70% in the central vein or ≥65% in mixed blood.

41. Septic shock IT directions:
 Infusion therapy
 ALV (in 40% of GRDS) in acute lung injury syndrome / adult respiratory
distress syndrome
 Cardiotonic and Vasotonic Support
(dopamine, norepinephrine, epinephrine, dobutamine)
 Correction of metabolic disorders, hyperglycemia
 Prevention of deep vein thrombosis
( low molecular weight fractionated heparins )
 Prevention of stress ulcers of the gastrointestinal tract
( H2 - blockers, proton pump inhibitors )
 Proteolysis inhibitors ( kontrikal ).

42. Therapy for septic shock
 Antibacterial therapy is of great importance:
 antibiotic therapy (broad spectrum according to the de-escalation scheme)
 antiseptics (dimexide, which, in addition to antibiotic therapy, has the
property of conducting other drugs in the tissue)
 Anti-inflammatory and membrane stabilizing therapy
of corticosteroids: prednisolone at a daily dose of 2000 mg.
 Prevention of "autocannibalism" (hyperutilization of skeletal muscle amino
acids). Parenterally: amino acids .