management of hemorrhagic and non hemorrhagic shock

1. Management of Hemmorhagic And
Non Hemmorhagic shock
Maaz BANGASH
Muhammad Saleem Khan
Fazl e Rehman

2. •Shock
• SHOCK is a life threatening situation due to poor
tissue perfusion with
• impaired cellular metabolism, manifested in turn by
serious
• physiological abnormalities. (Bailey and love)
• Shock is a term used to describe the clinical
syndrome that develops when
• there is critical impairment of tissue perfusion due to some
form of acute
• circulatory failure. (Davidson’s)

3. CONT...
• Shock may be defined as inadequate delivery of
oxygen and nutrients to
• maintain normal tissue and cellular function.(Schwartz’s)
• The state in which profound and widespread reduction
of effective tissue
• perfusion leads first to reversible, and then if prolonged, to
irreversible
• cellular injury. (Kumar and Parrillo ,1995)

4. •TYPES OF SHOCK
•1) HEMORRHAGIC AND
2)NON HEMORRHAGIC
SHOCK

5. NON HEMMORHAGIC SHOCK
• CARDIOGENIC SHOCK:
• Cardiogenic shock is a medical emergency resulting from
inadequate blood flow due to the dysfunction of the ventricles
of the heart. Signs of inadequate blood flow include low urine
production (<30 mL/hour), cool arms and legs, and altered
level of consciousness. People may also have a severely low
blood pressure and heart rate.
• Causes of cardiogenic shock include cardiomyopathY,
arrhythmiA, and mechanical weakness. CS is most
commonly precipitated by acute myocardial infarction.[6]

6. cont...
• Cardiogenic shock is a type of circulatory shock, there is
insufficient blood flow and oxygen supply for biological
tissues to meet the metabolic demands for oxygen and
nutrients. Cardiogenic shock is defined by sustained low
blood pressure with tissue hypoperfusion despite
adequate left ventricular filling pressure

7. SIGN AND SYMPTOMS OF C/S
• Signs and symptoms
• Anxiety, restlessness, altered mental state due to decreased
blood flow to the brain and subsequent hypoxia.
• Low blood pressure due to decrease in cardiac output.
• A rapid, weak, thready pulse due to decreased circulation
combined with tachycardia.
• Cool, clammy, and mottled skin (cutis marmorata) due to
vasoconstriction and subsequent hypoperfusion of the skin.
• Distended jugular veins due to increased jugular
venous pressure.

8. S/S CONT...
• Oliguria (low urine output) due to inadequate blood
flow to the kidneys if the condition persists.
• Rapid and deeper respirations (hyperventilation)
due to sympathetic nervous system stimulation and
acidosis.
• Fatigue due to hyperventilation and hypoxia.
• Absent pulse in fast and abnormal heart rhythms.
• Pulmonary edema, involving fluid back-up in the
lungs due to insufficient pumping of the heart.

9. OBSTRUCTIVE SHOCK
• Obstructive shock is a form of shock associated with
physical obstruction of the great vessels or the heart itself
• CAUSES OF O/S
• Cardiac tamponade
• Constrictive pericarditis (late stage)
• Aortic stenosis
• Tension pneumothorax
• anterior mediastinal mass

10. DSTRIBUTIVE SHOCK
• Distributive shock
• Distributive shock is a medical condition in which abnormal
distribution of blood flow in the smallest blood vessels results in
inadequate supply of blood to the body's tissues and organs. It
is one of four categories of shock, a condition where there is
not enough oxygen-carrying blood to meet the metabolic needs
of the cells which make up the body's tissues and organs.
Distributive shock is different from the other three categories of
shock in that it occurs even though the output of the heart is at
or above a normal level.[2] The most common cause is
sepsis leading to type of distributive shock called septic
shock, a condition that can be fatal.

11. CAUSES OF D/S
• SEPSIS
• ANAPHYLACTIC SHOCK
• Causes of adrenal insufficiency leading to
distributive shock
• removal of the adrenal glands
• reactions to drugs or toxins, heavy metal
poisoning
• and damage to the central nervous system.

12. Hemorrhagic shock
• Hypovolemic shock; is a life-threatening condition that
results when you lose more than 20 percent (one-fifth) of
your body’s blood or fluid supply. This severe fluid loss
makes it impossible for the heart to pump a sufficient
amount of blood to your body. Hypovolemic shock can
lead to organ failure.

13. CAUSES OF H/S
• Hypovolemic shock results from significant and sudden blood or fluid
losses within your body. Blood loss of this magnitude can occur
because of:
• bleeding from serious cuts or wounds
• bleeding from blunt traumatic injuries due to accidents
• internal bleeding from abdominal organs or ruptured ectopic pregnancy
• bleeding from the digestive tract
• significant vaginal bleeding• Endometriosis

14. CONT...
• In addition to actual blood loss, the loss of body fluids
can cause a decrease in blood volume. This can occur
in cases of:
• excessive or prolonged diarrhea
• severe burn
• excessive vomiting
• excessive sweating

15. cont....
• Blood carries oxygen and other essential substances to
your organs and tissues. When heavy bleeding occurs,
there is not enough blood in circulation for the heart to be
an effective pump. Once your body loses these
substances faster than it can replace them, organs in your
body begin to shut down and the symptoms of shock
occur. Blood pressure plummets, which can be life-
threatening.

16. TYPES OF H/S
• • HemorrhagE INDUCED hypovolumia – trauma, GI
bleed, hemorrhagic
• pancreatitis, fractures
• • Fluid loss induced hypovolumia– Diarrhea, vomiting,
burns

17. • External/internal:
• • External haemorrhage: External haemorrhage is visible,
• revealed haemorrhage.
• • Internal haemorrhage: Internal haemorrhage is
• invisible, concealed haemorrhage. Internal bleeding
• may be concealed as in ruptured spleen or liver,
• fractured femur, or in
• cerebral haemorrhage. Concealed haemorrhage may
• become revealed as in haematemesis or melaena from
• a bleeding peptic ulcer, as in haematuria from a
• ruptured kidney, or via the vagina in accidental uterine
• haemorrhage of pregnancy

18. S/S OF INTERNAL HEMORRHAGE
• Signs and symptoms that may suggest significant
• internal hemorrhage include:
• – Bright red blood from mouth, rectum, or other
• orifice
• – Coffee-ground appearance of vomit
• – Melena (black, tarry stools)
• – Dizziness or syncope on sitting or standing
• – Orthostatic hypotension
• • Internal hemorrhage is associated with higher
• morbidity and mortality than external hemorrhage

19. treatment of cardiogenic shock
• Medications
• Fluids and plasma, given through an IV, and medications to treat cardiogenic
shock, work to increase your heart's pumping ability.
• Inotropic agents. You might be given medications to improve your heart
function, such as norepinephrine (Levophed) or dopamine, until other
treatments start to work.
• Aspirin. Emergency medical workers might give you aspirin immediately to
reduce blood clotting and keep your blood flowing through a narrowed artery.
Take an aspirin yourself while waiting for help to arrive only if your doctor has
previously told you to do so for symptoms of a heart attack.

20. cont...
• Thrombolytics. These drugs, also called clot busters or fibrinolytics, help
dissolve a blood clot that's blocking blood flow to your heart. The sooner you
receive a thrombolytic drug after a heart attack, the greater your chances of
survival. You'll likely receive thrombolytics, such as alteplase (Activase) or
reteplase (Retavase), only if emergency cardiac catheterization isn't
available.
• Antiplatelet medication. Emergency room doctors might give you drugs
similar to aspirin to help prevent new clots from forming. These include
medications, such as oral clopidogrel (Plavix), and platelet glycoprotein
IIb/IIIa receptor blockers, such as abciximab (Reopro), tirofiban (Aggrastat)
and eptifibatide (Integrilin), which are given through a vein (intravenously).
• Other blood-thinning medications. You'll likely be given other medications,
such as heparin, to make your blood less likely to form clots. IV or injectable
heparin usually is given during the first few days after a heart attack.

21. • Medical procedures
• Medical procedures to treat cardiogenic shock usually focus on restoring blood flow through
your heart. They include:
• Angioplasty and stenting. If a blockage is found during a cardiac catheterization, your doctor
can insert a long, thin tube (catheter) equipped with a special balloon through an artery,
usually in your leg, to a blocked artery in your heart. Once in position, the balloon is briefly
inflated to open the blockage.
• A metal mesh stent might be inserted into the artery to keep it open over time. In most cases,
you doctor will place a stent coated with a slow-releasing medication to help keep your artery
open.
• Balloon pump. Your doctor inserts a balloon pump in the main artery off of your heart (aorta).
The pump inflates and deflates within the aorta, helping blood flow and taking some of the
workload off your heart.
• Mechanical circulatory support. Methods newer than the balloon pump are being used to
help improve blood flow and supply oxygen to the body, such as extracorporeal membrane
oxygenation (ECMO).

22. Managing internal bleeding:
• • ABC’s
• • High concentration oxygen
• • Assist ventilations
• • Control external bleeding
• • Stabilize fractures
• • RICE – resuscitation, investigations, clinical
• examination, evaluation
 • Transport rapidly to appropriate facility. ABC for trauma
 CONTROL hemorrhage
 Obtain IV access and resuscitate with fluids and blood
o 2 liter crystalloid for adults
o 20 cc/kg crystalloid
 Long term critical care management

23. mechanical meaNS of Control of
external bleeding:
• • Pressure Dressing: Use bandage to secure dressing in
• place
• • Tourniquets:
vePelvic Binders
– Reduce pelvis volume
– Tamponade effect
Tourniquets
– Studied extensively
in war
– Good outcomes
– Safe and effective

24. Hemostatic Dressings
• Research advancing quickly
– Made of volcanic rock, clay, shells
– Actions:
•Direct compression
•Activation of clotting
•Adhesion
– Utility
•Speed of application (under fire)
•Pliable, Z Fold conformation

25. tranxemic acid
– DDerivative of AA Lysine - inhibits fibrinolysis
– Cochrane review (2007) 53 RCT’s Cardiac/Ortho
• Sig reduction in bleeding without thrombotic
complications
– CRASH2 trial (2010) Prospective RCT, > 20,000 pts
• Stat sig 1.5% reduction in mortality (overall)
• Subgroup analysis (Severe bleeding & early admin)
–Reduced bleeding by 30% IF given within 1 hour
– MATTERs trial (2011) Camp Bastion in Afghanistan
• Marked improvement in survival in most severely injured
compared to those who did not receive it
– Soldiers to carry autoinjectors on battlefield

26. fluid replacement in HEMORRHAGIC
SHOCK
• The primary treatment of hemorrhagic shock is to control
• the source of bleeding as soon as possible and to replace
• fluid.
• • In controlled hemorrhagic shock (CHS), where the source of
• bleeding has been occluded, fluid replacement is aimed
• toward normalization of hemodynamic parameters.
• • In uncontrolled hemorrhagic shock (UCHS), in which the
• bleeding has temporarily stopped because of hypotension,
• vasoconstriction, and clot formation, fluid treatment is
• aimed at restoration of radial pulse or restoration of
• sensorium or obtaining a blood pressure of 80 mm Hg by
• giving 250 mL of lactated Ringer's solution
• (hypotensive resuscitation).

27. • Crystalloid is the first fluid of choice for
• resuscitation. Immediately administer 2 L of isotonic
• sodium chloride solution or lactated Ringer’s
• solution in response to shock from blood loss.
• • Fluid administration should continue until the
• patient's hemodynamics become stabilized.
• Because crystalloids quickly leak from the vascular
• space, each liter of fluid expands the blood volume
• by 20-30%; therefore, 3 L of fluid need to be
• administered to raise the intravascular volume by 1

28. CONT....
• Alternatively, colloids restore volume in a 1:1
• ratio. Currently available colloids include human
• albumin, hydroxy-ethyl starch products (mixed in
• either 0.9% isotonic sodium chloride solution or
• lactated Ringer’s solution), or hypertonic salinedextran
combinations. The sole product that is
• avoided routinely in large-volume (>1500 mL/d)
• restoration is the hydroxy-ethyl starch product
• mixed in 0.9% isotonic sodium chloride solution
• because it has been associated with the induction
• of coagulopathy

29. CONT...
• In patients with hemorrhagic shock, hypertonic
• saline has the theoretical benefit of increasing
• intravascular volume with only small amounts of
• fluid. The combination of dextran and hypertonic
• saline may be beneficial in situations where
• infusion of large volumes of fluid may be harmful,
• such as in elderly persons with impaired cardiac
• activity.

30. CONT...
• • PRBCs should be transfused if the patient remains
• unstable after 2000 mL of crystalloid
• resuscitation. For acute situations, O-negative
• noncrossmatched blood should be administered.
• Administer 2 U rapidly, and note the response.
• For patients with active bleeding, several units of
• blood may be necessary.

31. CONT........
• There are recognized risks associated with the
• transfusion of large quantities of PRBCs. As a result,
• other modalities are being investigated. One such
• modality is hemoglobin-based oxygen carriers
• (HBOC)

32. CONT.....
• If at all possible, blood and crystalloid infusions
• should be delivered through a fluid warmer.
• • A blood sample for type and cross should be drawn,
• preferably before blood transfusions are begun.
• • Start type-specific blood when available.
• • Patients who require large amounts of transfusion
• inevitably will become coagulopathic.

33. CONT.....
• FFP generally is infused when the patient shows signs
• of coagulopathy, usually after 6-8 U of PRBCs.
• • Platelets become depleted with large blood
• transfusions.
• • Platelet transfusion is also recommended when a
• coagulopathy develops.