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![SHOCK
• Inadequate tissue perfusion
• Clinical shock is usually accompanied by
hypotension ( meanarterial pressure [MAP]
<60)
• First step- Cause
• Goal: reverse tissue hypoperfusion
•](https://image.slidesharecdn.com/approachtoshock-190427165338/75/Approach-to-shock-4-2048.jpg)
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Approach to shock
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- 2. Refrences: • Harrisons Principlesof internal medicine 19th edition • Washington Manual of Critical Care 2nd edition
- 4. SHOCK • Inadequate tissueperfusion • 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 Pulsepressure 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 • Chestpain: 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
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- 10. General Examination • Levelof consciuosness • Toxic Looking • Cyanosis • Smell of alcohol • Evidence of trauma Blood pressure* normal/elevated (Early) Tachypnoeic
- 11. Respiratory findings • Ralesin 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 Solidorgan tenderness Peritonitis Rectal bleed
- 14. Nervous system • GCS •Pupils • Movements • Reflexes
- 15. Investigations CBC Urine routine RBS Electrolytes UREA/Blood UreaNitrogen Blood culture
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- 17. Monitoring • Blood Pressure, SPo2 , Intake/output • Central Venous Pressure • Arterial-Venous Blood GAS • Lactate • End tidal Co2
- 18. Miscellaenous causes • ThyroidStorm • AV malformation • Spinal Shock • Anaphylaxis • Adrenal Insufficiency • Pulmonary Embolism
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- 20. Hypovolemic Shock Most common Bloodloss • Hemoglobin and hematocrit • Hypernatremia
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- 23. Adjunctive therapies • FFP/Plateletadministration • 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 • Septicshock = sepsis +hypotension • Gram -ve bacteria(E.coli, Psuedomonas) • Hyperventilation –respiratory alkalosis-early sign • acrocyanosis
- 27. • ischemic necrosisdigits. • Cellulitis， • pustules， • Bullae • No specific diagnostic test • Removal of focus of infection
- 28. Complications • ARDS • RenALfailure acute tubular necrosis • Coagulopathy • Delirium • Immunosuppression
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- 31. Neurogenic shock • highcervical 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 • Anaphylaxisand Anaphylactois reactions • IgE mediated hypersenstivity reaction- anaphylaxis • Reaction < 1hour – rapid- parenetral • Flushing, Pruritis –intial symptoms
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- 37. Remember • Hypotension thatdoes 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
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