SHOCK

SHOCK

1. WHAT IS IT?

   • It´s a physiologic state characterize by systemic reduction in tissue perfusion.

2. WHAT HAPPENS?

   • Circulation fails to provide the metabolic need of tissue and fails to remove waste products.
     • The result is inadequate blood flow, therefore oxygen = failure of tissue oxygenation

3. WHAT ARE THE EFFECTS?

   • Decrease of gas exchange : Taquipnea
   • Because of increase of ADH (reabsorption of water)
   • Decrease perfusion : drowsy (CNS)
   • Coagulation abnormalities: Disseminated intravascular coagulation
   • Decrease CO: Hypotension
   • Decrease Glomerular Filtration Rate: urine output
   • increase enzyme levels: Mucosal ischemia

4. CATEGORIES

   • CARDIOGENIC
     • Myocardial infarction
     • Depressed pump function
     • Abnormal rythm
     • Beta blockers, Ca channel blockers
     • Congestive Heart Failure
     • Valvular heart disease
     • Cardiac arhythmias
   • OBSTRUCTIVE
     • Pulmonic embolism
     • Pericardical tamponade
     • Tension pneumotorax
   • METABOLIC/ RESPIRATORY
     • Disturbances in oxygen diffusion, carrying, off loading or used by cells.
   • HYPOVOLEMIC
     • Not Hemorrhagic
       • Plasma / body water loss
     • Hemorrhagic
     • Electrolytes imbalance.
       • Vomiting.
       • Diarrhea.
       • Dehydration.
   • DISTRIBUTIVE
     • SEPTIC
       • Virus, bacterias, protozoos
     • ANAPHYLACTIC
       • Injections, Anaesthetics, Stings, Shelfish.
     • NEUROGENIC
       • Quadriplegia.
       • Trauma to spinal cord.
       • Paraplegia.
       • Spinal anesthesia

5. TYPES

   • Mild Shock
     • Collapse of subcutaneous veins of extremities esp. the feet, which become pale and cold
       • Sweat on forehead, hand and feet, urine output normal, pulse rate normal. Blood pressure normal,patient feels thirsty and cold.
   • Moderate Shock
     • drowsiness, oliguria, pulse rate increased, blood pressure normal then falls in later stage.
   • Severe Shock
     • unconsciousness, gasp, anuria, rapid pulse, profound, hypotension

6. MONITORING

   • MONITORING
     • Blood pressure, Heart rate, Respiratory rate, Urine output, Blood CBC, Pulse-oximetry, ECG, U / S, CT, X-ray
   • SPECIAL MONITORING
     • Central venous pressure, Inadequacy of blood volume, CVP>12cmH2O o Cardiac dysfunction, Cardiac output, Pulmonary catheter, Doppler, Pulse waveform analysis

7. STAGES OF SHOCK

   • Non-progressive
     • Attempt to correct the metabolic disorder of shock.
   • Progressive
     • Compensation starts to fail
   • Initial
     • Cells become leaky and switch to anaerobic metabolism.
   • Refractory
     • Shock no longer reversed, organ failure
   • EARLY SIGNS
     • LATE SIGNS
       • IRREVERSIBLE SHOCK AND DEATH

8. Resuscitation

   • Principles of Resuscitation
     • A. AIRWAY
     • B. BREATHING
     • C.. CIRCULATION
   • End Points of Resuscitation
     • Classic: Homeostatic restoration
     • Improved: Normalization of serum lactate levels, Resolution of base deficit, Adequate - MVS
     • Goal directed approach Urine output > 0.5 mL/kg/hr, CVP 5 -10 cm H2o, MAP 65 to 90 mmHg, Central venous oxygen concentration > 70%

9. Guidelines

   • Treat the cause
     • Improve Cardiac function
     • Improve Tissue perfusion

10. Fluid Therapy

    • Dynamic Fluid Response
    • Crystalloid Solutions
    • Colloid Solutions
    • Blood transfusion

11. Oxygen Carrying Capacity

    • Red blood cells oxygen carrying capacity
    • Replacement of other solutions to support volume
    • Improve end organ perfusion wont provide additional oxygen carrying capacity

12. Vasopressors / Inotropic Drugs

    • Other TreatmentS
      • Steriods , Antibiotics, Catheterisation, Nasal O2 / Ventilatory support , CVP Line, Control of Pain, ICU - Critical care management
    • Phenylephrine / NA
    • Septic shock / Neurogenic
    • Inotropics - Dobutamine

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