shock, It's classification and management

1. Shock and It’sShock and It’s
ManagementManagement
Dr. Md. Arifuzzaman
Resident
Hepatobiliary Surgery
BSMMU, Dhaka

2. ShockShock
Shock is a systemic state of low tissue perfusion
which is inadequate for normal cellular respiration.
With insufficient delivery of oxygen and glucose, cells
switch from aerobic to anaerobic metabolism. If
perfusion is not restored in a timely fashion, cell death
occur.
Basic pathology is inadequate (Not always low)
cardiac output for the metabolic needs of the tissue.

3. Classification of shockClassification of shock
■ Hypovolaemic shock
■ Cardiogenic shock
■ Obstructive shock
■ Distributive shock
■ Endocrine shock

4. Hypovolaemic Shock causeHypovolaemic Shock cause
 Haemorrhagic
 Non-haemorrhagic.
 Poor fluid intake (dehydration)
 Burn
 Excessive fluid loss due to
 vomiting,
 diarrhoea,
 urinary loss (eg. diabetes),
 evaporation

5. Shock-CausesShock-Causes
Cardiogenic (Pump failure)
Eg. M.I, Cardiac contusion, tension pneumothorax,
cardiac tamponade, pulmonary embolus.

6. Obstructive shock-causeObstructive shock-cause
Cardiac tamponade,
tension pneumothorax,
massive pulmonary embolus
air embolus
IVC obstruction

7. Shock-causeShock-cause
 Distributive shock-Cause
Septic shock,
anaphylaxis and
spinal cord injury.
 Endocrine shock-cause
 hyperthyroidism
 hypothyroidism
 adrenal insufficiency

8. PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Initial stage
Compensatory stage
Progressive stage
Refractory stage

9. Initial stageInitial stage
 Hypo-perfusion leads to hypoxia.
lactic acid begins to accumulate,
leading to lactic acidosis.

10. compensatory stagecompensatory stage
 Physiologic response to hypovolemia is directed at preservation of
perfusion to vital organs.
 Stimulation of renin angiotensin system in order to increase cardiac
contractility & peripheral vascular tone
 Release of Anti-Diuretic Hormone (ADH) to reabsorbe salt and water.
 Change in local micro circulation to regulate regional blood flow.
 Victim begins to Hyperventilate
 Mediation via Baro & chemo receptors which stimulates ANS & HPA
axis to Release of epinephrine & norepinephrine.

11. Compensatory (Hormonal response)Compensatory (Hormonal response)
HyperglycemiaLypolysisGluconeogenesisGlycogenolysis
Cortisol
ACTH
CRH
HYPOTHALAMUS

12. ProgressiveProgressive stagestage
When compensatory mechanism begins to fail.
Anaerobic metabolism progresses, increasing
metabolic acidosis.

13. Refractory stageRefractory stage
There is organ failure.
Shock is irreversible.
Brain damages and cells die.
Finally death occurs.

14. Signs and SymptomsSigns and Symptoms
Restless, anxious, confused and thirsty
Cold pheriphery
Cyanosed with a rapid feeble pulse
sweating
Hypotension
Low urine output
Hyperventilation

15. Signs-ContdSigns-Contd
CVP decreased (But in Cardiogenic shock patient
have increased CVP)
Heart rate increased, but in cardiogenic shock, HR
is normal or decreased
Cardiac output decreased but in early stages of
septicemic shock. It can be increased due to
hyperdynamic circulation.

16. MANAGEMENT OF SHOCK:MANAGEMENT OF SHOCK:
GENERAL Principles of shock managementGENERAL Principles of shock management
The overall goal of shock management is to improve oxygen
delivery in order to prevent cellular and organ injury.
Effective therapy requires treatment of the underlying cause.
Restoration of adequate perfusion, monitoring and
comprehensive supportive care.
Achieving an adequate B.P increasing cardiac output and
optimizing oxygen content of the blood
Oxygen demand should also be reduced.

17. Initial Treatment in ShockInitial Treatment in Shock
-Assess airway and breathing Airway and begin CPR if
necessary.
-Lay the person down.
-Elevate feet unless head, neck, hip or leg is injured.
-Turn patient to his side if vomiting or bleeding from the
mouth.
-Keep patient warm.
-Administer oxygen if available.
-Treat obvious injuries.
-Administer volume expansions (usually Normal Saline).

18. Maintain Breathing:Maintain Breathing:
Give 100% oxygen
If Breathing effort inadequate
Artificial respiration by
-Mouth to mouth breathing
-Respiratory bag after intubation
-Mechanical ventilator

19. Maintain Circulation:Maintain Circulation:
 Control obvious haemorrhage
 Insert two large bore IV cannula
 Take blood for grouping, cross matching
 Start IV infusion
-Normal saline/Ringer lactate
-Plasma expanders-Dextran 70,
Haemacel,
-Whole blood in moderate to severe
blood loss to maintain Hb >10 gms%
and hematocrit >30%.

20. Restoration of CirculationRestoration of Circulation
VOLUME- FLUID CHOICES:VOLUME- FLUID CHOICES:
CRYSTALLOIDS VS COLLOIDSCRYSTALLOIDS VS COLLOIDS
Crystalloids: for initial resuscitation
IVF 0.9% Normal Saline is the fluid of
choice. Give 250-500ml over 5-10 min.
 Hartmann’s solution ,Ringers lactate may
also be used.

21. Colloids: to replace blood loss
Albumin
Dextran
Blood
 They are great volume expanders used for major
haemorrhage

22. INVESTIGATIONSINVESTIGATIONS
 Blood test
• CBC
• Blood grouping
• Arterial blood gas analysis
 Fasting Blood Sugar (FBS)
 Random Blood Sugar (RBS)
 Microscopic Culture and Sensitivity test (MCS)
 CXR
 Electrocardiogram (ECG)
 Echocardiogram (ECHO)

23. DRUGS USED IN SHOCKDRUGS USED IN SHOCK
MANAGEMENTMANAGEMENT
Inotropes –cardiac support
Vasopressins
Steroids

24. InotropesInotropes
Agent Site of Action Dose
Mcg/kg/min
Effects
Dopamine Dopaminergic
Beta
Alpha < Beta
1-3
5-10
11-20
Renal vasodilation
Inotrope/vasoconstriction in order to increase BP
Increase peripheral. Vascular resistance
Dobutamine Beta 1 & 2 1-20 Inotrope
Vasodilation
Epineprhine Beta < alpha 0.05 – 1.0 Inotrope, vasoconstriction
Tachycardia
Norepinephrine Alpha < beta 0.05 – 1.0 Profound vasoconstriction
inotrope
Nitroprusside Vasodilator
(arterial < venous)
0.5 – 1.0 Vasodilation
Milranone Phosphodiesterase inhibitor 0.5 – 0.75 Inotrope
vasodilation

25. VasopressinVasopressin
 Initiates reabsorption of water by the kidney
 Also causes constriction of blood vessels.
 Blood flow diversion from non-vital to vital
organs
 Dosage 0.01 – 0.04U/min up to 0.08U/min IV

26. SteroidsSteroids
Glucocorticoid function
-Maintain homeostasis.
-Increases BP.
-Modulate inflammatory response.
-Normalize vascular reactivity.
-Boosts blood glucose level.
Dosage: Hydrocortisone 200 mg IV

27. Hypovolemic shockHypovolemic shock
It occur when the intra vascular volume is
depleted relative to the vascular capacity.
Mild (<15%) Moderate(15-40%) Severe(<40%)
-Cold
extremities
-Inreased CRT
-Diaphoresis
-Anxiety
Same +
-Tachycardia
-Tachypnoea
-Oliguria
-Postural
hypotension
Same +
-Hypotension
-Mental status
deterioration

28. Management OF Hypovolemic ShockManagement OF Hypovolemic Shock
 I.V. fluid normal saline 250-500 ml over 5-10 min.
 If hemodynamic instability persist then start blood
transfusion & control on going heamorrhage.
 Give Inotropes:
Dopamine 5-10microgms/Kg/min
Dobutamine 1-20microgms/Kg/min

29. Circulatory pump failure
Sustained hypotension
SBP < 90 mm Hg for at
least 30 minutes.
MANIFESTATIONS
 Chest pain
 Hypotension
 Arrhythmias
Cardiogenic shockCardiogenic shock
MANAGEMENT:
 Confirmation of diagnosis by
ECG, ECHO & X-RAY.
 Intubation & mechanical
ventilation often required.
 Avoid fluid overload.
 Inotropic support preferably
Dobutamine 2-
20microgms/Kg/min.

30. Decreased tissue perfusion as
a result of loss of vasomotor
tone to peripheral arterial beds
Secondary to spinal cord injury
from vertebral
Hypotension with bradycardia
Warm extremities
Motor and sensory deficit
Neurogenic shockNeurogenic shock
MANAGEMENT
Restoration of
intravascular volume by
crystalloids
Administer
vasoconstrictors:
Dopamine
<10mcg/kg/min

31.  Blood flow is stopped as a
result of cardiac (or pericardiac)
tamponade (the build-up of fluid
in the pericardium) that
compresses the heart and stops
it from beating properly , or
pulmonary embolism ( a blood
clot in the pulmonary artery,
blocking the flow of blood to the
lungs)
OBSTRUCTIVE SHOCKOBSTRUCTIVE SHOCK
MANAGEMENT
Removing the obstruction
, for example,surgery or
clot-dissolving medication
(heparin 3000-5000units
IV) to remove a clot in the
pulmonary artery.

32. -Have 2 stage(hyper &
hypodynamic) with
different manifestation.
-Immune system should
work properly for every
recovery.
-Body temp gives the clue
from differentiate other
types
Septic shockSeptic shock MANAGEMENT
 Culture of body fluids
 Infuse fluid 500 cc/15min
monitor SBP/CVP
 If hemodynamic instability
persists start vasopressor
preferably Norepinephrine 0.02-
0.25microgms/Kg/min
 Administer broad spectrum
antibiotic –must given

33. CONCLUSIONCONCLUSION
Early recognition and diagnosis in the initial stage is
important for successful management of shock.
Hypovolemia and sepsis account for majority of shock.
Principles of initial resuscitation same irrespective of type
of shock.
Should treat first irrespective of other medical or surgical
codition
Ultimate treatment of underlying cause forms cornerstone
of management.

34. Thank YouThank You