Shock in surgery

1. Surgical shock
Definition
Physiopathology
Kind of shock
management

2. definition
 1872, S.D Gross: a rude unhinging of the
machinery of life.
 Shock most commonly occurs from circulatory
failure with hypotension , sys BP<90
Cellular/tissue hypoxia due to delivary of
oxygen or consumption of oxygen.

3. Circulation delivery of O2 to cell.
tissue perfusion/delivery of O2 or
consumption of o2 Or inadequate O2
Cellular hypoxia membrane ion pump
Dysfunction intracellular edema

4. Leakage of intracellular content into
extracellular space inadequate regulation
of intracellular PH exacerbation of
Cellular hypoxia.

5. Cardiac output/systemic vascular resistance
BP CO SVR
CO HR SVstroke volume
SV: preload/myocardiac contractility/afterload
SVR : length/diameter vessel and blood
viscosity.

6. Any change these parameters will alter BP
And result SHOCK.
SHOCK hase several stages .
early or preshock :compensatory responses to
diminished tissue perfusion .(reversible)
Shock: sign/symptom of organ dysfunction.
End_organ dysfunction: MOF(irreversible)Death

7. HYPOVOLEMIC SHOCK
Hypovolemic shock results from reduced
intravascular volume, causing a reduced
preload and reduced CO.
Hypovolemic shock is divided into hemorrhagic
and nonhemorrhagic

8. Common Etiologies of Hypovolemia

Hemorrhagic:

Blunt or penetrating trauma

Upper gastrointestinal bleed

Lower gastrointestinal bleed

Intra- and postoperative bleeding

Ruptured abdominal aortic aneurysm

Aortoenteric fistula

Hemorrhagic pancreatitis

Iatrogenic

Tumor or abscess erosion into major vessel

Postpartum hemorrhage, uterine, or vaginal
hemorrhage

9. Nonhemorrhagic

Gastrointestinal losses from diarrhea,
vomiting, or external

Skin losses

drainage

Renal losses

Third space losses into extravascular
space or body cavities

15. Classes of Hemorrhagic Shock
4
3
2
1
>40
(>2,000
mL)
30–40
(1,500–
2,000 mL
15–30
(750–1,500
mL)
<15 (<750
mL)
Blood loss
(%)
>
140
>
120
>
100
<
100
Pulse
↓↓
Normal
Normal
Blood
pressure
Negligible
5
–
10
20
–
30
30 or more
Urine
output
(mL/hr)
Confused
and
lethargic
Anxious
and
confused
Mildly
anxious
Slightly
anxious
Mental
status
>
40
30
–
40
20
–
30
14
–
20
Respiratory
rate

16. Diagnosing hypovolemic shock starts with a
history and physical, which usually leads one
to the cause of the hypovolemia.

17. The management of hypovolemic shock
rapid volume repletion:In hemorrhagic
hypovolemic shock, isotonic crystalloid
resuscitation should be limited to 1 to 2 L of
intravenous (IV) fluid with early transition to
blood and plasma. 1:2 resuscitation (1 unit of
plasma for every 2 units of packed blood cells)
.

18. Avoidance of hypothermia and correction of
acidosis and coagulopathy interrupt the “lethal
.
.
triad of trauma,” a known risk factor for death

20. Isotonic saline solutions (Table 5-4)
are the preferred fluid in
nonhemorrhagic shock

21. Isotonic saline solutions are the preferred fluid
in nonhemorrhagic shock.
Administered as a bolus of 20 to 30 mL/kg,
and repeated every 5 to 10 minutes,
fluid repletion should continue at the initial
rate until clinical markers of resuscitation (BP,
urine output, mental status, and peripheral
.
perfusion) improve

22. Components of Different Isotonic
Intravenous Fluids
Othe
r
Gluc
ose
Ca2
K+
Cl−
Na+
pH
Osm
olari
ty
(mO
sm/
L)
Lacta
te 28
-
3
4
109
130
6.5
273
Lacta
ted
Ringe
r
--
-
-
154
154
6
308
NS
0.9%
Dext
ran
100
-
-
-
154
154
4
308
10%
Dextr
an 40
in NS

23. DISTRIBUTIVE SHOCK
Distributive shock : excessive vasodilatation of
the peripheral vasculature resulting in the
impaired distribution of blood flow.
Septic shock :most common form
anaphylactic
neurogenic shock
adrenal crisis

24. Septic Shock
The original definition required a source of
infection plus two
or more systemic inflammatory response
syndrome (SIRS) criteria (temperature >
38.5°C or <36°C, HR > 90
beats/minute, respiratory rate > 20
breaths/minute or PaO2 < 32 mm Hg, and
white blood cell count
>12,000/mm3, <4,000/mm3, or >10%
.
immature bands

25. sepsis is
life-threatening organ dysfunction caused by a
dysregulated host response to infection.
Sepsis is identified through use of the
Sequential Organ Failure
Assessment (SOFA) score .
The SOFA score assesses six major organ
systems, applying a numeric value to the level
of failure for each system.

26. Sequential Organ Failure Assessment
(SOFA) Score Criteria
 Respiratory: PaO2/FiO2 (mmHg)
 Coagulation: platelets ×103/μL
 Liver: bilirubin (mg/dL)

Cardiovascular: mean arterial
pressure or administration of
vasopressors required
 CNS: Glasgow coma scale
Renal: creatinine (mg/dL) (or
urine output

27. The diagnosis of sepsis/septic shock starts with
a thorough physical examination. Classically
febrile or hypothermic with tachycardia and
tachypnea. Initially,
warm and Clammay, skin mottling
And cool sensation to touch.
lab tests can assist in the diagnosis of
sepsis/septic shock.

28. management of sepsis/septic shock
first and foremost, is source control.
resuscitation and life support
Broad-spectrum antibiotics : the first hour of
sepsis recognition.
The risk of dying from septic shock increases
by 10% per hour of delay to antibiotics.
Fluid management: a 30 mL/kg crystalloid
infusion in the first 3 hours of the identification
of sepsis.

29. Norepinephrine as the first-line agent with
both
.
vasoconstrictive and inotropic properties
Epinephrine as the second-line therapy
s Dopamine as the third-line agent
Phenylephrine should not be used in septic
shock.
Septic shock refractory to IV fluid/vasopressor
may require the hydrocortisone 50 mg every 6
hours

30. Neurogenic Shock
Neurogenic shock is most commonly a result of
traumatic injury to the spinal cord at the level
of the sixth thoracic vertebra and higher,
estimated to occur in up to 20% of cervical
.
spine injurie
s complete dysregulation of the sympathetic
nervous system, causing inappropriate
vasodilation and resultant
hypotension, bradyarrhythmias, and
temperature dysregulation

31. Neurogenic shock is not to be confused with spinal
shock
 . The first step : IV fluid , 1to 2 L of isotonic
crystalloid
 adding a vasopressor if not
obtained with fluid resuscitation.
 Phenylephrine is the first-line therapy for
neurogenic shock without bradycardia
 Norepinephrine is often the first-line therapy if
both hypotension and bradycardia are
present.

32. Anaphylactic Shock
Anaphylactic shock is a severe allergic reaction
that affects multiple organ systems, but most
importantly, the cardiovascular and respiratory
systems.
Ig E binds the Ag, causing a massive release
of inflammatory mediators such as histamine
that cause smooth muscle contraction within
the bronchi, severe vasodilatation leaking
capillaries, and depressed heart contractility.
.

33. The majority of anaphylactic reactions are
diagnosed clinically.
Treatment is supportive
. 125 mg of IV methylprednisolone
Epinephrine should be injected at a
dose of 0.3 to 0.5 mg intramuscularly with
repeat dosing every 5 to 15 minutes as needed
H1 and H2 antihistamines should be
administered to effectively block histamine
receptors.

34. OBSTRUCTIVE SHOCK
The etiologies are divided: pulmonary
vascular and mechanical.
Right ventricular failure : PE or PH
Mechanical causes : tension pneumothorax
(PTX), pericardial tamponade,
constrictive pericarditis, and restrictive
cardiomyopathy.

35. tension PTX
The diagnosis of a tension pneumothorax is made
on physical examination. The triad of absen

breath sounds, shock, and muffled heart sounds
confirm the diagnosis.

Immediate treatment is directed

decompressing the intrapleural hypertension.
This is accomplished by either placing a large
angiocat

into the second intercostal space at the
midclavicular line or inserting a chest tube at the
anterior axillary lin

in the fourth or fifth intercostal space.

36. CARDIOGENIC SHOCK

Cardiogenic shock is defined as sudden failure
heart pump itself.

causes : myocardial infarction (MI), cardiac
arrhythmias, cardiomyopathy, heart

valve problems, aortic valve stenosis or aortic
dissection, and ventriculoseptal defects..

Diagnosis starts with a thorough bedside

history and physical