Shock <br />Dr. Tanuj Paul Bhatia<br />
Definition <br />Inadequate delivery of oxygen and nutrients to maintain normal tissue and cellular function.<br />
DISTRIBUTION OF BODY FLUIDS<br />
TYPES OF SHOCK<br />Hypovolemic shock<br />Septic shock<br />Cardiogenic shock<br />Neurogenic shock<br />Anaphylactic sho...
Hypovolaemic shock<br />Most common form seen clinically.<br />Results from depletion of circulating blood volume.<br />Th...
Pathophysiology<br />
Autoregulation<br />
Other mechanisms <br />Renin from JGA,<br />Angiotensin ,<br />Aldosterone from adrenal cortex,<br />Anti-diuretic hormone...
<ul><li>Despite these adjustments cells become starved.</li></ul>Anerobic metabolism and lactic acidosis.<br />Sustained h...
Clinical picture<br />
Mild hypovolaemia<br />Deficit <20% of blood volume.<br />Cool, damp extremities.<br />Patient is thirsty.<br />Maybe chil...
Moderate hypovolemia<br />Deficit of 20%-40% of blood volume.<br />Cold extremities.<br />Thirst.<br />Chills.<br />Modera...
Severe hypovolaemia<br />Deficit >40% of blood volume.<br />All above signs.<br />Decreased urinary output.<br />Rapid, th...
Parameters α competence of circulation<br />Level of cerebral activity.<br />Hourly urine output (normal = 30-50ml/hr in a...
Investigations <br />Baseline investigations.<br />ABG = arterial blood gases (pH,pO2,pCO2)<br />ECG monitoring.<br />Seru...
Management <br />Aim – to increase cardiac output and tissue perfusion.<br />Plan :<br />    1. Tackle the primary problem...
Outline of treatment<br />Resuscitation  = A + B<br />Fluid replacement<br /><ul><li>Crystalloid solution used for initial...
Glucose should not be used as it may cause diuresis  and further depletion of circulating volume.
2 litres of crystalloid are given as fast as possible in sever shock.
Severity of shock determines the rate of fluid.
CVP acts as a guideline.</li></ul>3. Positioning: elevation of both legs.<br />
Classification of hypovolemicShock<br />Class	        EBLTreatment<br />I	<15% (<750ml)	                 Fluids<br />II	15...
Vasopressor drugs<br />Use of vasopressor drugs not recommended in routine.<br />They raise blood pressure by increasing p...
Indicators of successful resuscitation<br />Warm skin.<br />Well perfused skin.<br />Urine output 30-60 ml/hr.<br />Alert ...
Venous access<br />Peripheral line <br />Central line<br /><ul><li>Femoral
Internal jugular
Subclavian</li></li></ul><li>Parenteral fluid therapy<br />Crystalloids<br />Isotonic<br />Hypertonic<br />Hypotonic <br /...
Crystalloids <br />Crystalloids are solutions that contain sodium as the major osmotically active particle.<br />Relativel...
Isotonic crystalloids<br />E.g.. Lactated ringer’s solution(RL), 0.9% NaCl(normal saline)<br />Distribute uniformly throug...
Other crystalloids<br />Hypertonic saline solutions(e.g. 10%NaCl) : can be used for resuscitation in combination with coll...
Colloid solutions<br />Contain high–molecular-weight substances that remain in the intravascular space.<br />Lessens the t...
Maintenance fluids <br />100 mL/kg per day for the first 10 kg.<br />50 mL/kg per day for the second 10 kg.<br /> 20 mL/kg...
THANK YOU<br />
Glasgow coma score<br />
SEPTIC SHOCK  <br />
Septic shock<br />Results either by gram +ve or gram –ve bacterial infection.<br />Gram –ve sepsis is more dangerous, comm...
Respiratory tract
Intestines.
Commonly involved gram –ve organisms are E. coli, Proteus, Klebsiella, P. aeruginosa.</li></li></ul><li>Why is gram negati...
Pathophysiology of septic shock<br />‘ENDOTOXINS’<br />Bacterial lipopolysaccharides.<br />Part of bacterial cell wall.<br...
These lead to :-<br />Activation of complement, fibrinolytic, kinin systems,<br />Activation of platelets and neutrophils....
Risk factors for septic shock<br />Liver failure,<br />Immune deficiency,<br />Diabetes,<br />Malnutrition,<br />Long term...
MOFS/MODS<br />Multi organ failure/dysfunction syndrome.<br />Mediators from neutrophils act in a non specific fashion, wh...
Clinical presentation of septic shock<br />EARLY RECOGNITION IS VERY IMPORTANT<br />Chills,<br />Elevated temperature abov...
Management <br />Shift to ICU,<br />CVP monitoring,<br />Urinary output monitoring,<br />IV fluid infusion : RL@20ml/kg bo...
Pulmonary therapy<br />Sepsis endothelial damage to pulmonary capillaries.<br />Pronounced alveolar injury, interstitial ...
CARDIOGENIC SHOCK<br />
Etiology <br />Massive myocardial infarction<br />Severe valvular heart disease<br />Arrhythmias<br />Pulmonary embolism –...
Pathogenesis <br />
Diagnosis <br />Previous history of cardiovascular disease,<br />Distended neck veins,<br />Low BP,<br />Peripheral edema,...
Treatment <br />Opioids to relieve pain and provide sedation.<br />Diuretics, decrease afterload ,alleviate peripheral and...
NEUROGENIC SHOCK<br />
Neurogenic shock<br />
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Shock

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Shock

  1. 1. Shock <br />Dr. Tanuj Paul Bhatia<br />
  2. 2. Definition <br />Inadequate delivery of oxygen and nutrients to maintain normal tissue and cellular function.<br />
  3. 3. DISTRIBUTION OF BODY FLUIDS<br />
  4. 4.
  5. 5.
  6. 6. TYPES OF SHOCK<br />Hypovolemic shock<br />Septic shock<br />Cardiogenic shock<br />Neurogenic shock<br />Anaphylactic shock <br />
  7. 7. Hypovolaemic shock<br />Most common form seen clinically.<br />Results from depletion of circulating blood volume.<br />This may result from<br />Hemorrhage<br />Plasma loss eg. Burns<br />Loss of ECF eg. <br /> Intestinal fistulas,<br />Vomiting<br />Diarrhoea<br />
  8. 8. Pathophysiology<br />
  9. 9. Autoregulation<br />
  10. 10. Other mechanisms <br />Renin from JGA,<br />Angiotensin ,<br />Aldosterone from adrenal cortex,<br />Anti-diuretic hormone from pituitary<br />
  11. 11. <ul><li>Despite these adjustments cells become starved.</li></ul>Anerobic metabolism and lactic acidosis.<br />Sustained hypoxia.<br />“Sick cell syndrome”<br />
  12. 12. Clinical picture<br />
  13. 13. Mild hypovolaemia<br />Deficit <20% of blood volume.<br />Cool, damp extremities.<br />Patient is thirsty.<br />Maybe chilly.<br />UOP and BP are normal in supine position but BP may fall on standing.<br />
  14. 14. Moderate hypovolemia<br />Deficit of 20%-40% of blood volume.<br />Cold extremities.<br />Thirst.<br />Chills.<br />Moderate tachycardia.<br />Decreased urine output.<br />BP falls in standing position but may be normal in supine position.<br />
  15. 15. Severe hypovolaemia<br />Deficit >40% of blood volume.<br />All above signs.<br />Decreased urinary output.<br />Rapid, thready pulse.<br />Low BP.<br />Restlessness and agitation due to decreased cerebral perfusion.<br />
  16. 16. Parameters α competence of circulation<br />Level of cerebral activity.<br />Hourly urine output (normal = 30-50ml/hr in adults).<br />Central venous pressure.<br />Normal range of CVP is 3-5 cm of H2O above the manubriosternal angle.<br />
  17. 17. Investigations <br />Baseline investigations.<br />ABG = arterial blood gases (pH,pO2,pCO2)<br />ECG monitoring.<br />Serum electrolytes.<br />
  18. 18. Management <br />Aim – to increase cardiac output and tissue perfusion.<br />Plan :<br /> 1. Tackle the primary problem eg. Hemorrhage.<br /> 2. Adequate fluid replacement.<br /> 3. Improving cardiac function with inotropic drugs.<br /> 4. Correcting acid base disturbance and electrolyte abnormalities.<br />
  19. 19. Outline of treatment<br />Resuscitation = A + B<br />Fluid replacement<br /><ul><li>Crystalloid solution used for initial resuscitation.
  20. 20. Glucose should not be used as it may cause diuresis and further depletion of circulating volume.
  21. 21. 2 litres of crystalloid are given as fast as possible in sever shock.
  22. 22. Severity of shock determines the rate of fluid.
  23. 23. CVP acts as a guideline.</li></ul>3. Positioning: elevation of both legs.<br />
  24. 24. Classification of hypovolemicShock<br />Class EBLTreatment<br />I <15% (<750ml) Fluids<br />II 15-30% (750-1.5L) Fluids<br />III 30-40% (1.5L-2.0L) Fluids + Blood<br />IV >40% (>2.0L) Fluids + Blood<br />
  25. 25. Vasopressor drugs<br />Use of vasopressor drugs not recommended in routine.<br />They raise blood pressure by increasing peripheral vascular resistance  decreasing tissue perfusion.<br />Inotropic drugs like Dopamine and Dobutamine may need to be used to improve cardiac action.<br />
  26. 26. Indicators of successful resuscitation<br />Warm skin.<br />Well perfused skin.<br />Urine output 30-60 ml/hr.<br />Alert sensorium. <br />
  27. 27. Venous access<br />Peripheral line <br />Central line<br /><ul><li>Femoral
  28. 28. Internal jugular
  29. 29. Subclavian</li></li></ul><li>Parenteral fluid therapy<br />Crystalloids<br />Isotonic<br />Hypertonic<br />Hypotonic <br />Colloids <br />Albumin preperations<br />Dextran<br />Hydroxyethyl starch <br />
  30. 30. Crystalloids <br />Crystalloids are solutions that contain sodium as the major osmotically active particle.<br />Relatively inexpensive<br />Readily available<br />Useful for :<br /> - volume expansion<br /> - maintenance infusion<br /> - correction of electrolyte disorders <br />
  31. 31. Isotonic crystalloids<br />E.g.. Lactated ringer’s solution(RL), 0.9% NaCl(normal saline)<br />Distribute uniformly throughout the ECF.<br />RL mimics ECF and is considered a BALANCED SALT SOLUTION.<br />RL preferred for replacing GI losses and extracellular fluid volume losses.<br />Normal Saline preferred in the presence of hyperkalemia, hypercalcemia, hyponatremia, hypochloremia, or metabolic alkalosis.<br />
  32. 32. Other crystalloids<br />Hypertonic saline solutions(e.g. 10%NaCl) : can be used for resuscitation in combination with colloids.<br />BUT, there is more danger of complications like hypernatremia, hyperchloremia, hypokalemia with rapid infusion.<br />Hypotonic saline solutions (e.g. 0.45%NaCL): <br />expand the intravascular compartment by as little as 10% of the volume infused.<br />Not used for resuscitation for the same reason.<br />
  33. 33. Colloid solutions<br />Contain high–molecular-weight substances that remain in the intravascular space.<br />Lessens the total amount of fluid needed for resuscitation.<br />Substantially more expensive than crystalloids .<br />Indicated when crystalloids fail to sustain plasma volume because of low colloid osmotic pressure. E.g. Burns.<br />E.g. Dextran, Albumin preperations, Hydroxyethyl starch.<br />
  34. 34. Maintenance fluids <br />100 mL/kg per day for the first 10 kg.<br />50 mL/kg per day for the second 10 kg.<br /> 20 mL/kg per day for each subsequent 10 kg.<br />
  35. 35. THANK YOU<br />
  36. 36. Glasgow coma score<br />
  37. 37. SEPTIC SHOCK <br />
  38. 38. Septic shock<br />Results either by gram +ve or gram –ve bacterial infection.<br />Gram –ve sepsis is more dangerous, common scources of gram –ve organisms are:<br /><ul><li>Genitourinary tract
  39. 39. Respiratory tract
  40. 40. Intestines.
  41. 41. Commonly involved gram –ve organisms are E. coli, Proteus, Klebsiella, P. aeruginosa.</li></li></ul><li>Why is gram negative sepsis becoming more important?<br />There is indiscriminate use of potent antibiotics now a days.<br />Leads to development of virulent RESISTANT ORGANISMS. <br />Hospitals are major reservoir of such infection.<br />This can easily transmit from one patient to another.<br />
  42. 42. Pathophysiology of septic shock<br />‘ENDOTOXINS’<br />Bacterial lipopolysaccharides.<br />Part of bacterial cell wall.<br />Released mainly when bacteria die.<br />
  43. 43. These lead to :-<br />Activation of complement, fibrinolytic, kinin systems,<br />Activation of platelets and neutrophils.<br />Endovascular injury at microvascular level.<br />Sudden release of vasoactive substances from injured endo. cells .<br />Macrophage stimulation and release of mediators ( IL-6,TNF,Arachidonic acid metabolites)<br />All these further lead to more endovascular damage.<br />
  44. 44.
  45. 45. Risk factors for septic shock<br />Liver failure,<br />Immune deficiency,<br />Diabetes,<br />Malnutrition,<br />Long term steroid administration,<br />Cytotoxic drugs,<br />Massive bacterial load. E.g. intestinal perforation.<br />
  46. 46. MOFS/MODS<br />Multi organ failure/dysfunction syndrome.<br />Mediators from neutrophils act in a non specific fashion, when activated systemically, can produce injury to normal micro-circulation.<br />Features : <br />Stress ulceration,<br />Biochemical signs of liver failure,<br />Lethargy,<br />May progress to coma and later death.<br />
  47. 47. Clinical presentation of septic shock<br />EARLY RECOGNITION IS VERY IMPORTANT<br />Chills,<br />Elevated temperature above 101 F,<br />Hyperventilation,<br />Oliguria,<br />Altered sensorium,<br />White blood cell count is raised.<br />
  48. 48. Management <br />Shift to ICU,<br />CVP monitoring,<br />Urinary output monitoring,<br />IV fluid infusion : RL@20ml/kg bolus..... further Mx according to CVP.<br />Thorough search of the source of infection.<br />Drain the infective process as soon and when possible.<br />
  49. 49. Pulmonary therapy<br />Sepsis endothelial damage to pulmonary capillaries.<br />Pronounced alveolar injury, interstitial oedema and hemorrhage.<br />Treatment is by maintaining controlled airway and an assisted ventilation.<br />Not needed if sepsis is controlled early.<br />
  50. 50. CARDIOGENIC SHOCK<br />
  51. 51. Etiology <br />Massive myocardial infarction<br />Severe valvular heart disease<br />Arrhythmias<br />Pulmonary embolism – right side of heart comes under sudden strain.<br />
  52. 52. Pathogenesis <br />
  53. 53. Diagnosis <br />Previous history of cardiovascular disease,<br />Distended neck veins,<br />Low BP,<br />Peripheral edema,<br />Enlarged and tender liver,<br />Rales on lung auscultation,<br />ECG signs of ischaemia,<br />Enlarged heart on X Ray.<br />
  54. 54. Treatment <br />Opioids to relieve pain and provide sedation.<br />Diuretics, decrease afterload ,alleviate peripheral and pulmonary edema.<br />Inotropic drugs improve cardiac contractility. E.g. dopamine in low doses.<br />Sometimes, Mechanical support to heart with an intra aortic balloon.<br />
  55. 55. NEUROGENIC SHOCK<br />
  56. 56. Neurogenic shock<br />
  57. 57. Pathogenesis <br />
  58. 58. Vasovagal or psychogenic shock<br />
  59. 59.
  60. 60. Treatment of neurogenic shock<br />Volume expansion with crystalloids,<br />Vasoconstrictors are useful.<br />Goal is to increase BP to sustain coronary perfusion.<br />Trendelenburg’s position can be temporarily useful.<br />Short term steroids may also be useful.<br />
  61. 61. Anaphylactic shock<br />Known to follow penicillin injection or administration of serum.<br />
  62. 62. Treatment of anaphylactic shock<br />Aqueous epinephrine 0.5-1 ml of 1:1000 solution given i.v.<br />Repeat dose may be given in 5-10 minutes.<br />Steroids.<br />O2 administration.<br />Volume expandors and pressor agents.<br />
  63. 63. THANK YOU<br />

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