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Shock - Pathophysiology / Types & Management

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This PPT on Shock is typically based on the Topic given in Bailey & Love. It will be useful to MBBS students - Final year.

Published in: Health & Medicine
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Shock - Pathophysiology / Types & Management

  1. 1. SHOCK [ Pathophysiology,Types & Mgt ]  Prof. Utham Murali. M.S; M.B.A
  2. 2. Objectives  Definition  Review basic physiologic aspects of shock  Different categories with Etiology &Clinical features  Management aspects
  3. 3. Definition Shock is a physiologic state characterized by systemic reduction in tissue perfusion, resulting in decreased tissue oxygen delivery. 3
  4. 4. Other Ways * It’s a condition, in which circulation fails to meet the metabolic need of the tissue & at the same time fails to remove the metabolic waste products. • Inadequate tissue perfusion to meet tissue demands • Usually result of inadequate blood flow and/or oxygen delivery • Inadequate peripheral perfusion leading to failure of tissue oxygenation • Lead to anaerobic metabolism 4
  5. 5. 5 Demand Supply
  6. 6. 6  Demand  Supply Shock
  7. 7. Pathophysiology of Shock
  8. 8. Cells switch from aerobic to anaerobic metabolism lactic acid production Cell function ceases & swells membrane becomes more permeable electrolytes & fluids seep in & out of cell Na+/K+ pump impaired mitochondria damage cell death
  9. 9. Shock – Effects on Organ  Heart – ↓ CO / hypotension / myocardial depressants  Lung - ↓gas exchange / tachypnoea / pulmonary edema  Endocrine – ADH → ↑ reabsorption of water  CNS – perfusion ↓ – drowsy  Blood - Coagulation abnormalities – DIC  Renal - ↓ GFR - ↓ urine output  GIT – mucosal ischaemia – bleeding & hepatic - ↑ enzyme levels
  10. 10. 11
  11. 11. HYPOVOLAEMIC ETIOLOGY  Blood loss.  haemorrhage  Plasma / body water loss.  Electrolytes imbalance.  Vomiting.  Diarrhea.  Dehydration.
  12. 12. Valvular heart disease Myocardial infarction. Cardiac arrhythmias. Cardiomyopathy CARDIOGENIC ETIOLOGY
  13. 13. OBSTRUCTIVE ETIOLOGY  Cardiac Tamponade  Pulmonary Embolism  Tension Pneumothorax  Air embolism
  14. 14. NEUROGENIC ETIOLOGY Paraplegia. Quadriplegia. Trauma to spinal cord. Spinal anesthesia.
  15. 15. ANAPHYLACTIC ETIOLOGY Injections - Penicillins. Anaesthetics Stings. Shelfish.
  16. 16. Gram + Gram - Fungi / Virus Protozoa SEPTIC ETIOLOGY
  17. 17. ENDOCRINE ETIOLOGY Hypo & Hyperthyroidism. Adrenal insufficiency.
  18. 18. Clinical Features Features of shock depend on the degree of loss of volume & on duration of shock. Types  Mild shock.  Moderate shock.  Severe shock.
  19. 19. Mild Shock Features  Collapse of subcutaneous veins of extremities esp. the feet, which become pale and cool  Sweat on forehead, hand and feet  Urine output normal.  Pulse rate normal.  Blood pressure normal.  Patient feels thirsty and cold.
  20. 20. Moderate Shock Features  Mild shock features + drowsy & confused  Oliguria  Pulse rate increased usually less then 100/min.  Blood pressure normal initially then falls in later stage.
  21. 21. Severe Shock Features  Unconscious.  Gasping respiration.  Anuria.  Rapid pulse.  Profound hypotension.
  22. 22. Stages of shock  Initial : The cells become leaky and switch to anaerobic metabolism.  Non-progressive:(compensated stage) Attempt to correct the metabolic upset of shock.  Progressive: (decompensated stage ) Eventually the compensation will begin to fail.  Refractory : Organs fail and the shock can no longer be reversed.
  23. 23. 24
  24. 24. SHOCK [ Management ]
  25. 25. Monitoring Blood pressure Heart rate Respiratory rate Urine output Blood CBC Pulse- oximetry ECG U/S , CT , X-ray
  26. 26. Special Monitoring  CARDIO – VASCULAR - Central venous pressure  Normal ; 5-10cmH2O,  If CVP<5cmH2O  Inadequacy of blood volume  CVP>12cmH2O  Cardiac dysfunction - Cardiac output  Pulmonary catheter  Doppler ultrasound  Pulse waveform analysis
  27. 27. Special Monitoring  SYSTEMIC & ORGAN PERFUSION  Clinical : urine output & LOC  Sr. Lactate estimation & Base defecit  Blood gas analysis  PO2 / PCO2 / ph  Mixed venous O2 saturation – N – 50-70%  Newer methods  Muscle tissue O2 probes  Near –infrared spectroscopy  Sublingual capnometry
  28. 28. Guidelines  Treat the cause  Improve Cardiac function  Improve Tissue perfusion
  29. 29. Goals of Resuscitation  Overall goal:  increase O2 delivery  decrease demand Treatment O2 content Cardiac output Blood pressure Sedation/analgesia
  30. 30. Principles of Resuscitation A: Airway patent upper airway B: Breathing adequate ventilation and oxygenation C: Circulation placement of adequate IV access  cardiac function  oxygenation
  31. 31. Fluid Therapy in Shock  Crystalloid Solutions  Normal saline  Ringers Lactate solution  Hartmann’s solution  Colloid Solutions  Blood transfusion
  32. 32. Oxygen Carrying Capacity  Only RBC contribute to oxygen carrying capacity (hemoglobin)  Replacement with all other solutions will  support volume  Improve end organ perfusion  Will Not provide additional oxygen carrying capacity
  33. 33. Dynamic Fluid Response  Infusing 250-500ml of Fluid rapidly in 5 - 10 mts.  Responders – Improvement  Transient responders – revert back  Non – responders
  34. 34. Vasopressors / Inotropic Drugs Vasopressors – Phenylephrine / NA  Distributive shock states  Septic shock / Neurogenic Inotropics - Dobutamine  Cardiogenic shock / Severe septic shock  To increase the cardiac output
  35. 35. Other Treatments  Correction of Acid – base balance  Steriods - Hydrocortisone  Antibiotics  Catheterisation  Nasal O2 / Ventilatory support  CVP Line  Control of Pain  ICU – Critical care management
  36. 36. End Points of Resuscitation Classic / Traditional  Restoration of blood pressure  Normalization of heart rate and urine output  Appropriate mental status Improved / Global  All of the above plus  Normalization of serum lactate levels  Resolution of base deficit  Adequate - MVS Goal directed approach  Urine output > 0.5 mL/kg/hr  CVP 5 -10 cm H2o  MAP 65 to 90 mmHg  Central venous oxygen concentration > 70%
  37. 37. Practically Speaking….  Know how to distinguish different types of shock and treat accordingly.  Look for early signs of shock.  Monitor the patient using the HR, MAP, mental status, urine output.  SHOCK is not equal to hypotension.  Start antibiotics within an hour !  Do not wait for cultures or blood work.
  38. 38. 1.All of the following are causes related to Obstructive shock except -  A Cardiac tamponade. B Air embolism. C Cardiac arrhythmias. D Pulmonary embolism.
  39. 39. 2.Which of the following is the agent of choice in Severe septic shock ?  A Vasopressin. B Adrenaline. C Phenylephrine. D Dobutamine.
  40. 40. 3. A 19-year-old male is brought to the hospital after sustaining an abdominal injury while playing rugby. He is complaining of left upper abdominal pain and has some bruising over the same area. His pulse is 140/min and his BP is 100/82mmHg. What is the type of shock?  A Septic shock. B Cardiogenic shock. C Hypovolaemic shock. D None of the above.
  41. 41. 4.Which of the following is not a newer methods for monitoring tissue perfusion - A Muscle tissue O2 probe. B Doppler ultrasound. C Infrared spectroscopy. D Sublingual capnometry.
  42. 42. 5.Which of the following is one of the last signs of shock ?  A Profound hypotension. B Tachycardia. C Prolonged capillary refill. D All of the above.
  43. 43. THANK YOU THANK YOU . . .

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