Types of Shock and their management-for MBBS students

1. SHOCK AND BLOOD
TRANSFUSION
Dr. Joel Danie Mathew
Assistant Professor
Department of General Surgery
BCMCH

3. SHOCK
A systemic state of low tissue perfusion, which is
inadequate for normal cellular respiration

4. 6
 Demand  Supply
Shock

5. Pathophysiology
 Cellular
 Microvascular
 Systemic - Cardiovascular, Respiratory, Renal
& Endocrine

6.  cellular
When perfusion to tissue
reduces
Dec O2 delivery to tissues
Cell metabolism
( aerobic -> anaerobic)
Accumalation of lactic acid in
blood
Systemic metabolic acidosis
Glucose within cells are
exhausted
Anaerobic respiration ceases
Failure of Na/K pump in the cell
membrane & intracellular
organelle
Intracellular lysosome release
autodigestive enzymes
Cell lysis & intracellular contents inc K
released into bloodsream

7. Microvascular
 Hypox ia & acidosis
 Activate compliment & prime neutrophils
 Generation of O2 free readicals & cytokine release
 Injury to capillary to endothelial cells
Further activation of immune system
Endothelial damage – leaky- tissue edema
Tissue ischemia
progresses
Activation of immune &
coagulation system

8. Systemic
 Cardiovascular
Preload &
afterload
Compensatory
baroreceptor
response
Increased Sympathetic
activity
Catecholamines release
into the circulation
Tachycardia
Systemic
vasoconstricti
on

9.  Respiratory
Metabolic acidosis
Inc. sympathetic stimulation
Tachypnea
Excretion of CO2
increased
Compensatory respiratory alkalosis

10.  Renal
Decreased renal
perfussion
Decreased glomerular filtration ->
decreased urine output
Stimulate RAAS
Vasoconstriction & inc. Na & water
reabsorption

11.  Endocrine
Hypothalamus
Adrenal cortex
Vasopressin
Cortisol
Vasoconstriction
Na & water
reabsorption
Sensitizing cells to
catecholamines

12. CLASSIFICATION OF SHOCK

13. •Hypovolemic Shock
•Cardiogenic shock
•Obstructive Shock
•Distributive shock
•Endocrine

14. Classification of shock
Hypovolemic shock
 Reduced circulatory volume
1. Haemorrhagic ( Internal / external bleeding)
2. Non Haemorrhagic ( dehydration, vomiting,
diarrhea, burns)

15. Cardiogenic Shock
 Primary failure of heart to pump blood to
tissues
 Causes : MI, Cardiac dysrhythmias,valvular
heart diseases, blunt myocardial injury &
cardiomyopathy

16.  Obstructive shock
 Reduction in preload because of mechanical
obstruction of cardiac filling
 Causes: Cardiac tamponade
Tension pneumothorax
Massive pulmonary embolus
Air embolus

17. Distributive Shock
 Inadequacy of intravascular volume
vascular vasodilatation with hypotension low
systemic vascular resistance, inadequate
afterload Abnormally high cardiac output
 Causes : Septic shock
Anaphylaxis
Spinal cord injury

18. Endocrine shock
 Combination of hypovolemic, cardiogenic &
distributive shock
 Hypothyroidism -> disordered cardiac & vascular
responsiveness to circulating catecholamines ->
neurogenic shock .
CO falls due to low inotropy & bradycardia
 Adrenal insufficiency- Hypovolemia & poor
response to circulating & exogenous
catecholamines -> shock

19. Severity of Shock
 Compensated
 Decompensated

20. Compensated mild moderate severe
Lactic acidosis + ++ ++ +++
Urine Output Normal Normal Reduced Anuric
Consciousness Normal MildAnxiety Drowsy Comatose
Respiratory rate Normal Increased Increased Laboured
Pulse rate Mild increase Increased Increased Increased
Blood Pressure Normal Normal Mild hypo Mild hypo

21. Resuscitation
A. Conduct of resuscitation:

22. Resuscitation
B. Fluid therapy:

23. SHOCK
STATUS:

24. Resuscitation
C.Vasopressor & Inotrope Support:

25. MONITORING

26. HAEMORRHAGE
Further haemorrhage
- > ↓ Perfusion to the
tissue - > unable to
generate heat
Coagulopathy
Hypothermia
Acidosis
Decrease function of coagulation
proteases - > coagulopathy
TraumaTriad of Death

27. Definitions:

28. Degree & Classification

29. Management:
After control
->aggressively
resuscitated,
warmed and
coagulopathy
corrected

30. Blood Transfusion
Definition:
Process of transferring whole blood or blood
components from one person (donor) to another
(recipient).
Indications:
Acute blood loss
Perioperative anemia
Symptomatic chronic anemia without haemorrhage or
impending surgery

31. Perioperative red blood cell
transfusion criteria
Source: Bailey & Love’s Short Practice of
Surgery25th ed

32. Blood & Blood
Products
Blood component Explanation
Whole blood
[can be broken down to:
RBC, platelets, fresh frozen
plasma (FFP)]
• Very rarely used
• Carries greater risks of adverse reactions
owing to the presence of leucocytes.
Packed Red Cell • Each unit isapproximately 330 ml and has
a
[do not provide viable platelets
or
haematocrit of 50–70%.
neutrophils] • For use in substantial hemorrhage &
anemia,
symptomatic anemia
Platelet
[for the coagulation; also
contain plasma (coagulation
factors), some red cells and
some white cells (leukocytes)]
• For patients with bleeding due to
either thrombocytopenia,
platelet dysfunction
• Temporary thrombocytopenia
occuring after radio- and
chemotherapy,
• Bleeding in patients with
thrombocytopenia or functional
platelet abnormality

33. Blood & Blood
Products
Blood component Explanation
Fresh frozen Plasma (FFP) • Corrections of known congenital or
acquired
[contains all coagulation factors in coagulation factor deficiencies.
normal amounts and is free of red
cells,
• Treatment of microvascular hemorrhage
in the
leukocytes and platelets] presence of prolonged PT,aPTT
Cryoprecipitate
[supernatant precipitate of FFP
and is rich in
factor VIII and fibrinogen]
• For Hemophilia A, von Willebrand
disease, DIC, Hypofibrinogenemia
(<100 mg/dl)
Factor VIII concentrates • Hemophilia A, & low titer factor VIII
inhibitors
Factor IX Concentrates • Hemophilia B

34. Complications of Blood
Transfusion

35. Single transfusion
 incompatibility haemolytic transfusion
reaction
 febrile transfusion reaction
 allergic reaction
 infection
 air embolism
 thrombophlebitis
 transfusion-related acute lung injury (TRALI)

36. Massive transfusion
 Coagulopathy
 Hypocalcemia
 Hyperkalaemia
 Hypokalaemia
 Hypothermia
 Iron overload

37. Management of
coagulopathy
 Correction of coagulopathy isnot necessary if no
active bleeding/ haemorrhage
 However, coagulopathy following during
massive transfusion should be anticipated
and managed aggressively
 Standard guidelines:
 FFP: if PTor PTT> 1.5 Xnormal;
 Cryoprecipitate : if fibrinogen < 0.8g/l
 Platelet : if platelet count < 50 x109ml

38. THANKYOU!