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Approach to shock
- 1. Approach to shock Gladwin Jeemon
- 2. Refrences: • Harrisons Principles of internal medicine 19th edition • Washington Manual of Critical Care 2nd edition
- 4. SHOCK • Inadequate tissue perfusion • Clinical shock is usually accompanied by hypotension ( meanarterial pressure [MAP] <60) • First step- Cause • Goal: reverse tissue hypoperfusion •
- 5. Identification • SBP <90mmhg • MAP<60mmhg SHOCK • Lactate ≥ 4 mmol/l • Reduced Cardiac output √ Cardiogenic/hypovolemic X Septic shock (Cardiac Index <2.2L/min/m2, measured by oesophageal doppler) Shock Index: Heart rate/SBP>0.9
- 6. Cardiogenic Hypovolemic Septic Pulse pressure Diastolic pressure Extremeties cool cool Warm Nailbed blood reurn Slow Slow Rapid JVP Respiratory crepitations +++ _ _ S3,S4 gallop rhytm +++ _ - Chest radiograph Large heart,pulmonary edema Diminished cardiac size Normal, /pnuemonia+ Identified site of infection _ _ ++++
- 7. Targeted History • Chest pain: MI,Pulmonary embolism • Trauma: Spinal, haemmorhage • Immunocompromised/fever • Medications: chronic use of steriods • GI loss • Abdominal Pain:Pancreatitis,Bowel Perforation
- 8. • Exposure:inhlation,hypo/hyperthermia • Hemorrhagic: hematuria,hematemesis • Sudden onset of hives • Vaginal bleeding
- 9. EXAMINATIONS
- 10. General Examination • Level of consciuosness • Toxic Looking • Cyanosis • Smell of alcohol • Evidence of trauma Blood pressure* normal/elevated (Early) Tachypnoeic
- 11. Respiratory findings • Rales in pulmonary edema • Wheezing with anaphylaxis • Air entry decreased in pnuemo/hydrothorax
- 12. CVS • Raised JVP • Muffled HS • S3 S4 gallop rhythm
- 13. GIT Evidence of trauma Solid organ tenderness Peritonitis Rectal bleed
- 14. Nervous system • GCS • Pupils • Movements • Reflexes
- 15. Investigations CBC Urine routine RBS Electrolytes UREA/Blood Urea Nitrogen Blood culture
- 16. Investigations Coagulation studies Chest Xray ECG Emergency ultrasound
- 17. Monitoring • Blood Pressure , SPo2 , Intake/output • Central Venous Pressure • Arterial-Venous Blood GAS • Lactate • End tidal Co2
- 18. Miscellaenous causes • Thyroid Storm • AV malformation • Spinal Shock • Anaphylaxis • Adrenal Insufficiency • Pulmonary Embolism
- 19. Types of shock
- 20. Hypovolemic Shock Most common Blood loss • Hemoglobin and hematocrit • Hypernatremia
- 22. Management
- 23. Adjunctive therapies • FFP/Platelet administration • Activated factor VII • Calcium chloride • Magnesium Chloride • Monitor and treat TRALI (transfusion related acute lung injury)
- 24. Cardiogenic shock- ETiology • Acute Myocardial infection • Congestive heartfailure • Acute myocarditis • Calcium channel or beta blocker overdose • HOCM • Aortic stenosis
- 26. Septic Shock • Septic shock = sepsis +hypotension • Gram -ve bacteria(E.coli, Psuedomonas) • Hyperventilation –respiratory alkalosis-early sign • acrocyanosis
- 27. • ischemic necrosis digits. • Cellulitis， • pustules， • Bullae • No specific diagnostic test • Removal of focus of infection
- 28. Complications • ARDS • RenAL failure acute tubular necrosis • Coagulopathy • Delirium • Immunosuppression
- 30. Antibiotics:
- 31. Neurogenic shock • high cervical spinalcord injury • inadvertent cephalad migration of spinal anesthesia • Head injury • warm extremities
- 32. • Treatment : relative hypovolemia and to the loss of vasomotor tone. • Excessive volumes of fluid may be required , if given alone. • Norepinephrine maintain mean arterial pressure
- 33. Anaphylactic shock • Anaphylaxis and Anaphylactois reactions • IgE mediated hypersenstivity reaction- anaphylaxis • Reaction < 1hour – rapid- parenetral • Flushing, Pruritis –intial symptoms
- 36. Management
- 37. Remember • Hypotension that does not respond to fluid replacement –Adrenal insufficency • Hydrocortisone (50 mg IV every 6 h) • improvement occurs - 24-48 h continue therapy for 5-7 days • Ventilator therapy - indicated for progressive hypoxemia, hypercapnia, neurological deterioration , respiratory muscle failure
- 38. Thank you