This document discusses obstetric shock, with a focus on hemorrhagic and septic shock. It defines shock and outlines the pathophysiology and continuum of systemic inflammatory response syndrome (SIRS) and shock. It discusses the mediators involved in SIRS and shock like cytokines, nitric oxide, and others. It also covers the hemodynamics of shock and how it can present as hyperdynamic, hypodynamic, or normodynamic. Treatment of hemorrhagic shock through fluid resuscitation and blood component therapy is outlined.
This topic contains definition, meaning, classification, pathophysiology, clinical menifestations, metabolic and general changes, management of obstetrical shock
Uterine Rupture
Deepa Mishra
Assistant Professor (OBG)
Introduction
Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth
Symptoms while classically including increased pain, vaginal bleeding, or a change in contractions are not always present.
Disability or death of the mother or baby may result.
Definition
Uterine rupture is giving way of gravid uterus or dissolution in the continuity of uterine wall anytime after 28 weeks of gestation with or without expulsion of the fetus.
Incidence
Rates of uterine rupture during vaginal birth following one previous C-section, done by the typical technique, are estimated at 0.9%
Rates are greater among those who have had multiple prior C-sections or an atypical type of C-section.
In those who do have uterine scarring, the risk during a vaginal birth is about 1 per 12,000
Risk of death of the baby is about 6%
Etiology
Risk Factors
Previous cesarean section
Myomectomy
Dysfunctional labor
Labor augmentation by oxytocin or prostaglandins
High parity
First pregnancy- very rare
Types of uterine rupture
Complete Rupture
All the layers including peritoneum are torn and the uterine contents escape into the peritoneal cavity.
Usually results in death
Incomplete Rupture
Visceral peritoneum is intact and usually the fetus remains in the uterine cavity
Sign & Symptoms
Uterine dehiscence and abdominal pain and vaginal bleeding
Deterioration of fetal heart rate
Loss of fetal station on manual vaginal exam
Hypovolemic shock due to intrabdominal bleeding
Chest pain between the scapulae, pain during inspiration due to irritation of blood below the perineum
Cessation of uterine contractions
Palpation of fetus outside the uterus
Signs of abdominal pregnancy
Post term pregnancy
Diagnosis
Signs of obstructed labor with dehydration, exhaustion, tachycardia raised temperature tonic contraction , pathological retraction ring
Absent fetal heart sound
On PV hot, dry vagina with a large caput over the presenting part
Prevention
Early diagnosis and management of CPD mal presentation and obstructed labor
Proper selection of cases for vaginal delivery
Carefull monitoring of oxytocin infusion specially in multipara
Avoid intra uterine manipulation no version in single fetus
Instrumental delivery after cervical dilatation
Immediate CS in obstructed labor
Hospital delivery for high risk cases
ECV should be avoided during general anaesthesia
Careful manual removal of placenta
Treatment
Resuscitation with adequate hydration and blood transfusion
Laprotomy
Hysterectomy
Repair
Complication
Rupture uterus with haemorrhage, shock and sepsis
Fetal loss is high in spontaneous and traumatic rupture
Mortality is low in LSCS scar rupture
This topic contains definition, meaning, classification, pathophysiology, clinical menifestations, metabolic and general changes, management of obstetrical shock
Uterine Rupture
Deepa Mishra
Assistant Professor (OBG)
Introduction
Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth
Symptoms while classically including increased pain, vaginal bleeding, or a change in contractions are not always present.
Disability or death of the mother or baby may result.
Definition
Uterine rupture is giving way of gravid uterus or dissolution in the continuity of uterine wall anytime after 28 weeks of gestation with or without expulsion of the fetus.
Incidence
Rates of uterine rupture during vaginal birth following one previous C-section, done by the typical technique, are estimated at 0.9%
Rates are greater among those who have had multiple prior C-sections or an atypical type of C-section.
In those who do have uterine scarring, the risk during a vaginal birth is about 1 per 12,000
Risk of death of the baby is about 6%
Etiology
Risk Factors
Previous cesarean section
Myomectomy
Dysfunctional labor
Labor augmentation by oxytocin or prostaglandins
High parity
First pregnancy- very rare
Types of uterine rupture
Complete Rupture
All the layers including peritoneum are torn and the uterine contents escape into the peritoneal cavity.
Usually results in death
Incomplete Rupture
Visceral peritoneum is intact and usually the fetus remains in the uterine cavity
Sign & Symptoms
Uterine dehiscence and abdominal pain and vaginal bleeding
Deterioration of fetal heart rate
Loss of fetal station on manual vaginal exam
Hypovolemic shock due to intrabdominal bleeding
Chest pain between the scapulae, pain during inspiration due to irritation of blood below the perineum
Cessation of uterine contractions
Palpation of fetus outside the uterus
Signs of abdominal pregnancy
Post term pregnancy
Diagnosis
Signs of obstructed labor with dehydration, exhaustion, tachycardia raised temperature tonic contraction , pathological retraction ring
Absent fetal heart sound
On PV hot, dry vagina with a large caput over the presenting part
Prevention
Early diagnosis and management of CPD mal presentation and obstructed labor
Proper selection of cases for vaginal delivery
Carefull monitoring of oxytocin infusion specially in multipara
Avoid intra uterine manipulation no version in single fetus
Instrumental delivery after cervical dilatation
Immediate CS in obstructed labor
Hospital delivery for high risk cases
ECV should be avoided during general anaesthesia
Careful manual removal of placenta
Treatment
Resuscitation with adequate hydration and blood transfusion
Laprotomy
Hysterectomy
Repair
Complication
Rupture uterus with haemorrhage, shock and sepsis
Fetal loss is high in spontaneous and traumatic rupture
Mortality is low in LSCS scar rupture
it contains a presentation on injuries that occur during baby birth
summary:
Maternal injuries following childbirth process are quite common.
VULVA
PERINEUM
RISK FACTORS FOR THIRD DEGREE PERINEL TEAR
REPAIR OF COMPLETE PERINEAL TEAR
VAGINA
CERVIX
PELVIC HEMATOMA
DIAGNOSIS OF RUPTURE UTERUS
Obstetrics and Gynecological Nursing
The PPT contains detailed information about Abnormal uterine action, its classifications, causes, sign and symptoms and management.
Please find the power point on Management of Preterm labor. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Please find the power point on Vacuum delivery. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
it contains a presentation on injuries that occur during baby birth
summary:
Maternal injuries following childbirth process are quite common.
VULVA
PERINEUM
RISK FACTORS FOR THIRD DEGREE PERINEL TEAR
REPAIR OF COMPLETE PERINEAL TEAR
VAGINA
CERVIX
PELVIC HEMATOMA
DIAGNOSIS OF RUPTURE UTERUS
Obstetrics and Gynecological Nursing
The PPT contains detailed information about Abnormal uterine action, its classifications, causes, sign and symptoms and management.
Please find the power point on Management of Preterm labor. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Please find the power point on Vacuum delivery. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
PowerPoint presentation describing various aspects of Pulmonary Hypertension. Please mail me your feedback on this presentation to following Email ID: tinkujoseph2010@gmail.com.
This topic covers the etiology, types, pathogenesis and management of Shock. It is very important for MBBS Students both theoretical & clinical aspect. Also they should know the hemodynamics across the types of shock in treating the patients....
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
2. OB Shock- Lecture
Organization
• Definition/Classification of Shock
• Pathophysiology of Shock
• Hemorrhagic Shock
• Sepsis (SIRS)
• Resuscitation
• Special Circumstances
3. Shock - Statistics
• One of the most common causes of death
in the US today
• Shock and Respiratory Failure together
account for majority of emergent ICU
admissions
• Shock mortality is high
(CDC, 1992; Rodriguez and Rosenthal, 1997)
4. Shock Statistics - Continued
• Septic Shock Mortality - 40%-60% (non-
pregnant)
• Septic Shock Mortality (Pregnancy) -
LOWER (20%- late septic shock-relative
lack of underlying diseases)
– younger age
– source/site
( NIH, 1992; Blanco, 1981; Porter, 1997)
5. Shock - Definition
• Functionally, “Shock” represents a
clinical condition in which intravascular
volume (and/or perfusion) is below
intravascular capacitance (and/or
demand)
• Operationally, “Shock” is broadly
divided into three types:
– Hypovolemic
– Cardiogenic
– Neurogenic
6. Shock - Obstetrics
• Lecture will focus predominantly on two
conditions that incite the
pathophysiologic cascade of shock:
– Hemorrhagic
– Septic
7. Shock - Pathophysiology
• Primary pathophysiologic mechanism in
shock is impaired oxygen utilization by
tissue
• Impaired utilization encompasses a
continuum
• Impaired utilization may be from:
– reduced perfusion
– deficient uptake
– abnormal relative perfusion
8. Shock - SIRS Continuum
• Shock represents one extreme of a continuum
of SYSTEMIC INFLAMMATORY
RESPONSE SYNDROME (SIRS)
• SIRS characterized by (any 2):
– Fever or hypothermia
– Pulse > 90/ min
– Tachypnea (> 20/min or PaCO2 < 32 torr
– Leukocytosis (> 12K), Relative Leukopenia (<4K),
or > 10% immature forms
14. Prostaglandins/Leukotrienes
PAF
• All are elevated in SIRS/SEPSIS and Shock
(and with ARDS)
• Animal studies with inhibitors are promising
• Human data from antagonist treatment not as
encouraging (NSAIDS may improve outcome in
hypothermic SEPSIS??)
(Haupt et al, 1991; Bone et al, 1989; Dhainaut et al, 1994; Arons et al, 1999)
15. Cytokines
• Cytokines are low MW proteins secreted by immune
cells that exhibit autocrine, paracrine, and/or endocrine
function
• Cytokines will induce hemodynamic effects of shock-
Clinical trials with inhibitors with mixed results
• Examples of cytokines:
– TNF alpha
– Interleukin (IL-1, IL-6, IL-8)
(Heard, 1997; Fisher, 1994)
16. Nitric Oxide (NO)
• Ubiquitous free radical inorganic gas/mediator
• TNF-a induces NO synthesis
• NO metabolites increase in Shock/SIRS/Sepsis
• Albeit blockage of NO pathway improves BP in
Shock (Sepsis), relative perfusion may suffer
and apropriate neutrophil response may be
impaired (issue is multi-modal and complex?)
(Malawista, 1992 and others)
17. Conclusions- Shock/SIRS
(Mediators)
• Process is a continuum
• Cascade of events may be initiated by a variety
of factors (with same final common pathway)
• Secondary tissue injury and progression of
syndrome is due to un-modulated (or mis-
modulated) immune response
• Mediator treatment promising, but not yet fully
developed
18. Hemodynamics of Shock
• Shock can be classified
hemodynamically-H
– Hyperdynamic
– Hypodynamic/Cardiogenic
– Hypovolemic (“Normodynamic”)
• Hemodynamics may change during
the natural progression of a
particular etiology of shock
19. Hemodynamics of Shock (2)
Cardiac
Output
LVEDV (Preload)
hyperdynamic
“normal”
hypodynamic
CO = HR x SV
MAP = CO x TPR
20. Hemodynamics of Shock (3)
• Septic shock is initially hyperdynamic (normal
filling pressure; enhanced contractility). BP
drop is related to decrease in SVR
• Hemorrhagic shock is initially normodynamic
(diminished filling pressure and CO; normal
LV function). BP drop is related to low CO
• Late Shock is usually hypodynamic with
increased SVR eventually progressing to total
systemic collapse
(Parker and Parillo, 1985; Lee, 1988; Porter, 1997)
21. Hemodynamics of Shock (4)
• Since MAP is determined by CO and TPR, hypotension
may be present with normal, elevated or decreased
contractility (CO)
• TPR (SVR) is usually initially increased with
hemorrhagic shock
• TPR (SVR) is usually decreased in early septic shock
• Late(irreversible) shock usually with low CO and
increased TPR (SVR) eventually progressing to total
systemic collapse as a terminal event
22. Hemodynamics of Shock (5)
• Acute lung injury in conjunction with
SIRS or shock may be -
– hydrostatic (elevated pressure)
– oncotic (lowered COP)
– capillary membrane (cell injury)
Pulmonary edema may be an inevitable consequence of
inappropriate or appropriate fluid therapy!
23. Hemodynamics of Shock -
Conclusions
• Hemodynamics may be bimodal or
trimodal
• Late shock is usually with high SVR and
diminished contractility
• Low filling pressures (low effective
perfusion volume) is an early feature of
all shock- the mechanisms are different,
however
24. OB Hemorrhagic Shock
• Hemorrhagic = Hypovolemic
• Leading cause of Obstetric death
• Significant cause of morbidity during
pregnancy and immediately postpartum
• May be poorly recognized due to
physiologic changes of pregnancy
(Berg, 1996; Clark, 1997)
25. Postpartum Hemorrhage
Traditional definition = > 500 ml blood loss
Normally seen blood losses:
Vaginal delivery - 50% > 500ml
C/Section- 1000ml
Elective C-hys - 1500ml
Emergent C-hys - 3000ml
26. Postpartum Hemorrhage (2)
Pregnancy is normally a state of
hypervolemia and increased RBC mass
Blood volume normally increased by 30%-
60% (1-2 L)
Pregnant patients are therefore able to
tolerate some degree of blood loss
Estimated blood loss is usually about 1/2 of
actual loss!
28. Categorization of Acute
Hemorrhage
Class 1 Class 2 Class 3
Blood loss
(% blood volume)
15% 15%-30% 30%-40%
Pulse rate <100 >100 >120
Pulse pressure Normal Decreased Decreased
Blood Pressure Normal or
increased
Decreased Decreased
29. OB Hemorrhage - Treatment
• First step in treatment is recognition
• Pregnant patients may have modified or
attenuated response to moderate blood loss
• Blood loss may not be noted at vaginal
delivery due to distraction
• Despite standards to the contrary, nursing
staff may be multi-tasked during critical post
partum period
31. Volume Therapy - Hemorrhagic
Shock
• In addition to volume loss from hemorrhage
itself, vascular damage produces pronounced
intravascular volume depletion
• First choice in treatment is crystalloid
(Lactated Ringers or 0.9 NS??)
• NO compelling advantage for the use of colloid
- outcome not different
• Volume = 3:1 - adjusted to clinical response
32. Volume Therapy - Hemorrhagic
Shock (2)
• NO improved outcome from use of PA catheters or
CVP- if present use them
• Restore volume as it was lost
• Warm fluids a MUST (OR “Cascade” warmer or
(better) trauma infuser)
• Endpoints (Positive and Negative)
– improved blood pressure
– improved mental status
– resumption of urine output
– pulmonary edema!!
33. Pulmonary Edema -
Hemorrhagic Shock
• May be consequence of appropriate
resuscitation (Acute lung injury/ARDS
continuum)
• Is easier to treat than oliguric ATN, myocardial
ischemia or acute brain injury
• In resuscitated, warm patient- can be suspected
by pulse oximetry changes
(Van Hook et al, 1997; Van Hook, 1998)
34. Monitoring
• Pulse oximetry - not accurate with hypothermia, low
cardiac output state, or as indicator of ventilatory
respiratory failure
• CVP - not generally indicated. If already present may or
may not reflect filling pressure
• PA-catheter - not generally indicated for primary
management. May be useful for evaluation of pulmonary
edema or in patient with an additional indication for
device
• Large-bore peripheral IV’s will deliver as much or more
volume as central lines do
• Consider continuous arterial blood pressure monitoring
• What is the patient’s pulse?
35. Blood Component Therapy -
Hemorrhagic Shock
• Packed RBC generally more available
than whole blood
• Fresh frozen plasma (FFP) not indicated
for volume replacement
• FFP not indicated for “prophylactic”
transfusion after arbitrary number of
packed RBC units
(NIH consensus, 1985)
36. Component Therapy -
Hemorrhage (2)
• Thrombocytopenia more apt to be
etiologic in massive transfusion bleeding
• Each unit donor platelets will raise
platelet count 5-10,000/cm3/M2- (Easy
way in normal size/weight patient = Each
unit will raise platelet count by
10,000/cm3/M2)
• Consider platelet transfusion with
platelet count less than 50,000/M2
37. Component Therapy -
Hemorrhage (3)
• FFP (Easy Way)
– replaces all clotting factors to degree found
in normal unit volume of blood
• Cryoprecipitate (Easy Way)
– “best” choice for hypofibrinogenemia (easy=
each unit raises fibrinogen 10 mg% - “target”
level often > 100mg%)
– used for Factor VIII, VWF, XIII, fibrinectin
38. Component Therapy -
Hemorrhage (4)
• Transfusion Goal Hematocrit (HCT):
– ISOVOLEMIA is more important than
arbitrary HCT for acute management - may
tolerate HCT as low as 18% if not bleeding
– some data suggest that increased DO2 may
improve outcome in hemorrhagic shock - O2
content only marginally increased as HCT
rises above 37%-30%
(Morrison et al, 1993; Shoemaker et al, 1987, Cunningham et al, 1997)
39. Adjunct Therapies - Hemorrhagic
Shock
• Vasopressors - Not useful as ab initio therapy
– use for “rescue” treatment
– will diminish tissue perfusion
• Renal Protective Therapy (0.5-2ug/kg/min
Dopamine) - questionably beneficial
• Inotropes (Oxygen delivery augmentation) -
may be helpful after initial resuscitation based
upon experience in trauma
40. Oxygen Delivery (DO2)
DO2= O2 Content X Cardiac Output
(Goal = > 650 mL/min/M2)
Content increased by:
a. Hematocrit
b. O2 saturation
Output increased by:
a. Inotropic agents
b. Volume tx.
(Shoemaker, 1987; Clark et al, 1997 and others)
41. Septic Shock
• SIRS (defined earlier) associated with
documented infection is termed SEPSIS
• SEVERE SEPSIS indicates the presence of organ
dysfunction, hypoperfusion, and/or hypotension
• SEPTIC SHOCK consists of severe sepsis
refractory to volume resuscitation
• MULTISYSTEM DYSFUNCTION SYNDROME
(MODS) is the terminal phase of this sequence of
events
(Bone et al, 1992; Porter, 1997)
42. Septic Shock - Background
• Progression from bacteremia into septic
shock is poorly predictable
• Exaggerated inflammatory response
predicts poorer outcome (APACHE II)
• Inflammatory mediators may mimic
syndrome
(Bone 1991; Bone, 1992; Rangel-Frausto, 1995)
43. Septic Shock - Obstetrics
• Septic Shock uncommon in Obstetric
patients
• Bacteremia rate (with infection) is approx.
8%-10%
• Up to 12% incidence of septic shock with
bacteremia
(Blanco, 1981; Duff, 1984; Balk, 1989; Porter, 1997)
45. Septic Shock - Pathophysiology
• (As delineated earlier) mechanism entails
mediator release as response to inciting event
• Secondary tissue injury, if unabated, incites
pathophysiologic cascade
• Originally described in response to G-negative
organisms (can occur with all organisms and
not in relationship to infections at all.
EXAMPLE - Hemorrhagic shock)
47. Clinical Progression of Septic
Shock
Early Shock Late Shock Irreversible Shock
Hypotension Hypotension Obtundation
Low SVR Cyanosis ARDS
Tachycardia Oliguria Anuria/azotemia
Elevated CO Acidemia Acidemia
Febrile Acute Lung Injury DIC
PAWP low PAWP + MSDS
CO decreased CO decreased
SVR variable SVR low
PAWP high
48. Septic Shock - Continued
• (Once again) - shock is a systemic disease!
• Myocardial dysfunction is a progressive feature
of septic shock-
– CO is initially increased (but not enough to meet
hypermetabolic demands)
– Direct myocardial depression occurs as a late and
progressive finding
– (Initial) low cardiac filling pressure aggravates
inadequate CO response
• Oxygen debt becomes the predominant
hemodynamic feature of progressive shock
(Porembka, 1993; Parrillo, 1985; Lee, 1988)
50. Antibiotic Treatment
• Specific recommendations beyond scope of
this talk
• OB/GYN infections usually should be
empirically treated by broad spectrum
therapy
• Once patient with full blown septic shock,
outcome not appreciably improved in era of
antibiotics!
51. Septic Shock - Treatment
• Volume Therapy - (see previous slides)
• Vasopressors - (as with hemorrhagic shock) are
only useful to “buy time” - may impair tissue
perfusion
• Mediator Therapy - (previously discussed)
presently disappointing (Corticosteroids?;
NSAID?)
52. Septic Shock Treatment - Inotrope
Therapy
• Augmentation of oxygen delivery (discussed
earlier) is not as efficacious in treatment of
sepsis-induced shock as it is in the treatment of
post-trauma patients
• Balance between excess lung water and tissue
perfusion often exists (most patients with full-
blown shock manifest ARDS)
(Shoemaker, 1987; NEJM, 1998 and others)
53. Lung Water vs. Perfusion
(Shock)
PULMONARY EDEMA
ORGAN
PERFUSION
Improved by:
diuresis
lower filling pressures
attenuation of hyperdynamics
Improved by:
volume
higher filling
hyperdynamics
54. Corticosteroids - Septic Shock
• High dose treatment popularized in the 1980’s
(“attenuate inflammation”)
• High dose treatment (30 mg/kg
methylprednisilone) = DISMAL FAILURE
• Recent data - lower dose corticosteroids (300-
450 mg/day hydrocortisone may be of benefit in
some patients (adrenal “replacement” dosing)
(Systemic Sepsis Cooperative Study Group, 1987; Crit Care Med, 1999)
55. “Best Approach” - Septic Shock
• EARLY RECOGNITION!!
• Early Antibiotic Treatment (before cascade
progresses)
• balance between perfusion and lung injury
• preservation of other organ systems (renal,
CNS, nutrition)
• minimize secondary morbidity (EXPERT
HELP)
• If able - control febrile morbidity
56. Trauma - Related Maternal
Adaptations to Pregnancy
Parameter Change Implications
Plasma volume Increases by 45%-50% Relative maternal
resistance to limited
blood loss
Red-cell mass Increases by 30% Dilutional anemia
Cardiac output Increases by 30%-50% Relative maternal
resistance to limited blood loss
Uteroplacenta 20%-30% shunt Uterine injury may
blood flow predispose to
increased blood loss
Increased uterine
vascularity
57. Trauma - Related Maternal
Adaptations to Pregnancy
Parameter Change Implications
Uterine size Dramatic increase Increased incidence of
uterine injury
with abdominal trauma
Change in position of
abdominal contents
Minute ventilation Increases by Diminished Paco2
25%-30% Diminished buffering
capacity
Functional residual Decreased Predisposition to atelectasis
volume and hypoxemia
Gastric emptying Delayed Predisposition to aspiration