shock

1. SHOCK
Dr HARSHA NANDINI TALASILA
M.S. Ortho

2. DEFINITION
• Shock is a systemic state of low tissue perfusion which is inadequate
for normal cellular respiration.

3. PATHOPHYSIOLOGY
Decreased tissue perfusion
Cells switch from aerobic to anaerobic respiration
Lactic acid
Systemic metabolic acidosis

4. • Hypoxia and acidosis activate complement and neutrophils
• Oxygen free radicals and cytokines released
• Injury to the capillary endothelial cells
• Loss of integrity of the endothelium
• Tissue oedema

5. EFFECTS OF SHOCK ON ORGANS
1. CARDIOVASCULAR
• preload and afterload decrease
• Compensatory baroreceptor response
• Increased sympathetic activity
• TACHYCARDIA

6. 2. RESPIRATORY
• Metabolic acidosis and increased sympathetic response
• Increased respiratory rate and minute ventilation
• Compensatory respiratory alkalosis

7. 3. RENAL
• Decreased renal perfusion
• Decreased urine output
4. ENDOCRINE
• ADH is released
• Vasoconstriction and water resorption

8. 5. CNS
• Decreased perfusion DROWSY
6. BLOOD
• Coagulation abnormalities DIC

9. TYPES OF SHOCK
1. Hypovolaemic shock
2. Cardiogenic shock
3. Obstructive shock
4. Distributive shock

10. HYPOVOLEMIC SHOCK
• Haemorrhagic
• Non haemorrhagic:
Dehydration
Vomiting
Diarrhoea
Urinary loss

11. CARDIOGENIC SHOCK
• Myocardial infarction
• Cardiac arrhythmias
• Valvular heart disease
• Cardiomyopathy

12. OBSTRUCTIVE SHOCK
• Cardiac tamponade
• Tension pneumothorax
• Massive pulmonary embolus

13. DISTRIBUTIVE SHOCK
• Septic shock
• Anaphylactic shock
• Spinal cord injury

14. SEPTIC SHOCK
• CLINICAL SIGNS: hyperthermia
tachycardia
wide pulse pressure
low blood pressure
Altered mental status

15. NEUROGENIC SHOCK
• Acute spinal cord injury
• Sympathetic outflow is disrupted
• Unopposed vagal tone
• Hypotension, bradycardia and hypothermia

16. SPINAL SHOCK
• Temporary dysfunction of spinal cord leading to loss of spinal reflexes
and sensorimotor function caudal to the level of injury.
• Manifested by flaccid paralysis, absence of anal wink and
bulbocavernous reflexes.
• Temporary phenomenon and recovers in 24 to 48 hours.

17. CLINICAL FEATURES
MILD SHOCK :
• Patient is anxious
• Cool peripheries
• Prolonged capillary refill time
• Tachycardia
• Tachypnoea
• Reduction in urine output

18. MODERATE SHOCK
• Patient is confused and drowsy
• Further tachycardia
• Urine output < 0.5ml /kg/hour

19. SEVERE SHOCK:
• Patient unconscious with laboured respiration
• Profound tachycardia and hypotension
• Urine output fall to zero

20. STAGES OF SHOCK
1. Initial stage : switch from aerobic to anaerobic respiration
2. Non progressive ( compensated stage ) : attempt to correct the
metabolic derangement
3. Progressive ( decompensated stage ) : compensatory mechanism
fail
4. Refractory: organ damage which cannot be reversed

21. MANAGEMENT

22. GOALS OF TREATMENT
1. Treat the cause
2. Improve cardiac output
3. Improve tissue perfusion

23. HYPOVOLEMIC SHOCK
• Airway, Breathing, Circulation
• Direct control of obvious bleeding: direct pressure control or
clamping of vessels
• Large bore venous access
• Fluid resuscitation
• Blood replacement
• Traction with Thomas splints, extremity splints to limit haemorrhage
from unstable fractures.

24. SEPTIC SHOCK
• INVESTIGATIONS: CBC,ABG with lactate,Blood culture, urine culture.
• TREATMENT : IV FLUIDS
Supplemental oxygen
Emperic antibiotics

25. NEUROGENIC SHOCK
• ABC
• Fluid resuscitation
• Bradycardia: Atropine
Pacemaker
• Methylprednisolone : used for blunt spinal cord injury.
High doses for first 24hours.

26. MONITORING
• Blood pressure
• Heart rate
• Respiratory rate
• Urine output
• Blood CBC
• Pulse- oximetry
• ECG
• U/S , CT , X-ray

27. SPECIAL MONITORING
Central venous pressure
• Normal : 5-10cmH2O,
• If CVP<5cmH2O: Inadequacy of blood volume
• CVP>12cmH2O: Cardiac dysfunction
Cardiac output
• Pulmonary catheter
• Doppler ultrasound

28. SYSTEMIC & ORGAN PERFUSION
• Clinical : urine output & LOC
• Sr. Lactate estimation & Base deficit
• Blood gas analysis
• PO2 / PCO2 / pH

29. END POINTS OF RESUSCITATION
• MAP : 65 to 90 mm of hg
• Urine output: >0.5ml/kg/hr
• CVP: 5 to 10 cm of H2O
• Central venous oxygen concentration >70%

30. THANK YOU