2. Definition
Kumar and Parrillo (1995) - “The state in which
profound and widespread reduction of effective
tissue perfusion leads first to reversible, and then
if prolonged, to irreversible cellular injury.”
Hypovolemic shock- inadequate fluid for vascular
system
Distributive shock- increased size of vascular system
Cardiogenic shock- inadequate pumping action
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course
4. Basic Physiology
• BP = CO x PR
• CO = SV x HR
4900ml =70ml x 70bpm
• Stroke Volume is a function
• Preload
• Afterload
• Myocardial Contractility
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course
6. What is Unique about Children
• Poor ability to concentrate urine
• Neonates & infants urine output 1 – 2ml/Kg/hr
• Compare elderly urine outuput <0.5ml/Kg/hr
• Blood vol 8 – 9% of ideal body weight
• Children have more insensible losses compared to adults
7. CLASSIFICATION OF CIRCULATORY SHOCK
• Cardiogenic shock - due to cardiac pump failure related to loss of
myocardial contractility/functional myocardium or
structural/mechanical failure of the cardiac anatomy and
characterized by elevations of diastolic filling pressures and volumes
9. OBSTRUCTIVE SHOCK
• Extra-cardiac obstructive shock - due to obstruction to flow in the
cardiovascular circuit and characterized by either impairment of
diastolic filling or excessive afterload
11. • Distributive shock - caused by loss of vasomotor control resulting in
arteriolar/venular dilatation and characterized (after fluid
resuscitation) by increased cardiac output and decreased VR
13. • Hypovolemic shock - due to decreased circulating blood volume in
relation to the total vascular capacity and characterized by a
reduction of diastolic filling pressures
15. CLINICAL CORRELATES OF HAEMORRHAGE
CLASS I CLASS II CLASS III CLASS IV
BLOOD LOSS
(ml)
= 750 750-1500 1500-2000 >2000
BLOOD LOSS % =15 15-30 30-40 >40
PULSE RATE <100 >100 >120 >140
BP NORMAL NORMAL DECREASED DECREASED
PULSE
PRESSURE
NORMAL/
INCREASED
DECREASED DECREASED DECREASED
ORTHOSTASIS ABSENT MINIMAL MARKED MARKED
CAP REFILL NORMAL DELAYED DELAYED DELAYED
RR 14-20 20-30 30-40 >34
UO (ml/hr) >30 20-30 5-15 <5
CNS MSE SLIGHT ANXIETY MILD ANXIETY ANXIOUS/
CONFUSED
CONFUSED/
LETHARGY
16. PHASES OF SHOCK
• Discrete phases based on physiological changes
• PHASES: (1) compensated phase (2) decompensated phase (3)
terminal shock
• Clinical signs vary with phases
• Prognosis depend on phase
17. Initial Patient Assessment
• Recognition of Shock
• Clinical signs and symptoms depends on the severity of
the shock
• Early manifestations include tachycardia and cutaneous
vasoconstriction
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Advanced Emergency Trauma Course
18. CLINICAL FEATURES
• Hypotension
• Rapid Pulse
• Cold skin and extremities
• Pale skin
• Intense thirst
• Rapid respirations
• Restlessness and coma
• History related to the cause
19. TREATMENT
• According to available protocols
• Pt prep is important
• Need to plan our surgery
• Need good pre op, intra op and post op care
• Anticipate haemorrhage in certain cases
20. • WHAT IF PATIENT COMES BLEEDING
• WHAT IF PATIENT COMES WITH BURNS
• WHAT IF PATIENT COMES WITH IO
21. Treating Hypovolemic Shock
• In SGY we have what we call the golden hour
ABCDEs + call for help
• Airway and Breathing
• Would prefer O2 sat greater than 95%
• Placing O2 on the patient
• Circulation
• Hemorrhage Control
• Vascular Access, Large bore IV x 2
• Xmatch
• IVF
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Advanced Emergency Trauma Course
23. Treating Hemorrhagic Shock
•Identify & reverse the cause
•Restore tissue perfusion
•Restore organ function
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24. Initial Fluid Therapy
• Adult with normal Cardiac Function
• 1 to 2 Liters of LR or NS rapidly
• Pediatric
• 20ml/kg of LR or NS rapidly
• Evaluate patients response to fluid
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course
25. THE CRYSTAL RANDOMISED TRIAL
• JAMA: effects of fluid resuscitation with colloids Vs crystalloids on
mortality in critically ill patients with hypovolaemic shock
• 359 (25.4%) deaths Colloids Vs 390 (27.0%) deaths in crystalloids. This
outcome was 28 day period mortality
• 434 (30.7%) colloid mortality over 90 days period Vs 493 (34.2%)
crystalloid mortality
26. Evaluation of Treatment
•Assess organ perfusion
•Urinary output
•Mental Status
•Skin exam
•Vitals
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course
27. MECHANISMS OF CELLULAR INJURY IN SHOCK
1) Cellular ischemia
2) Free radical reperfusion injury
3) Inflammatory mediators (local and circulating)
