classification and management of shock

1. SHOCK
By Dr. Mohammed Al Ameen

2. • Shock is an abnormality of the circulatory system
resulting in inadequate tissue perfusion and
oxygenation

3. Physiology of cardiac output
• CO = Heart Rate (HR) × Stroke Volume (SV)
• Preload, Myocardial contractility, Afterload
• Frank–Starling curve

4. Causes of shock
• Cardiac output falls
Hypovolaemic
Cardiogenic
Obstructive

5. • Systemic vascular resistance falls
Sepsis
Anaphylaxis
Neurogenic

6. Clinical features of shock
• ↑ Heart rate
• ↑ Respiratory rate
• ↓ Blood pressure
• Cool peripheries
• ↓ Conscious level
• ↓ Urine output

7. Class of
shock
Class 1 Class 2 class3 class4
Volume of
blood loss (ml)
Up to 750 750–1500 1500–2000 > 2000
Volume of
blood loss ( %
)
0–15 % 15–30 % 30–40 % > 40 %
Heart rate <100 > 100 > 120 > 140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure Normal or
increased
Decreased Decreased Decreased
Respiratory
rate
14–20 20–30 30–40 > 35
Mental state Slightly
anxious
Mildly anxious Anxious,
confused
Confused,
lethargic

8. Hemorrhagic shock
• Ill appearance or altered mental status
• Heart rate >100 beats/min
• Respiratory rate >20 breaths/min or PaCO2 <32 mm Hg
• Arterial base deficit <−4 mEq/L or lactate >4 mM/L
• Urine output <0.5 mL/kg/hr
• Arterial hypotension >30 continuous minutes duration

9. Cardiogenic shock
• Cardiac Failure : Clinical evidence of impaired forward
flow of the heart, including presence of dyspnea,
tachycardia, pulmonary edema, peripheral edema, or
cyanosis

10. • MI
• overdose
• complete heart block

11. • Myocardial contusion
• PE
• Cardiac tamponade
• Tension pneumothorax

12. Sepsis
• SIRS 1) Temperature > 38.3 ° C or <36 ° C.
2)Hear rate > 90 beats per minute.
3)Respiratory rate > 20 breaths per minute.
4)White cell count <4 or > 12 × 109 /L.
5)Acutely altered mental state.
6)Blood glucose > 8.3 mmol/L (in the absence of
diabetes).

13. • Sepsis = SIRS + Infection
• Severe sepsis = sepsis + organ dysfunction
• Septic shock

14. Anaphylaxis
• Respiratory
• Skin
• CVS
• GI tract

15. Investigations and monitoring in shock
• HR, BP, Spo2,
• Lactate
[(Lactate initial-Lactate delayed) / Lactate initial] * 100
• Central venous pressure (CVP) monitoring
• Central venous oxygen saturations (ScvO 2 )
• Invasive arterial pressure monitoring

16. Management of shock
• Airway and breathing – high flow O2 , early
intubation
• Circulation - 250 ml IV and re-assessed after
each
• Hemoglobin of 7–9 g/dl is a reasonable target in
otherwise healthy patients
• Inotropes and vasopressors

17. Inotropes and vasopressors
• α 1, β 1, β 2, Dopamine
• Inotropes — which increase cardiac contractility
Eg: Adrenaline, Dobutamine, Dopamine
• Vasopressors— which increase systemic vascular
resistance Eg: Noradrenaline, Phenylephrine,
• Dobutamine 5-15 μg/kg/min
• Dopamine 2-20 μg/kg/min
• Epinephrine 5-20 μg/min
• Norepinephrine 5-20 μg/min
• Phenylephrine 2-20 μg/min
• Inamrinone, Milrinone

18. Septic shock
• Early goal-directed therapy
CVP, MAP,Scvo2/lactate clearance(HCT)
• blood cultures
• antibiotic

19. Cardiogenic Shock
• Early intubation
• SBP< 100 + signs and symptoms of shock = norepi
• SBP 70-100 + no = dobutamine
• Intra-aortic balloon pump
• Aspirin
• Heparin / LMWH
• PCI

20. Hemorrhagic Shock
• ventilation and oxygenation
• immediate control of hemorrhage
• poor organ perfusion and 30-minute anticipated delay to
hemorrhage control, begin PRBC infusion (5-10 mL/kg)
• CNS trauma or GCS <9

21. • 32yrs old Pt was bought to ER with c/o of fever
and drowsiness since 3-4days,VITALS: HR-120,
BP-60/40, RR-28, Spo2-84, T- 103 F .
O/E: nuchal rigidity.
• Next step?
• Next step??
• Next step???

22. Thank you