SHOCK

Shock- Defined
Circulatory X-emotional state of

shock/Medical shock LIFE THREATENING MEDICAL EMERGENCY Inadequate oxygen consumption to meet peripheral tissue needs

shock POSITIVE FEEDBACK MECHANISM

Stages of Shock
INITIAL:
Hypoperfusion state Cells perform anaerobic Hypoxia Damage of cell

respiration
Build up of lactic acid

membranes Metabolic acidosis

and pyruvic acid

Stages of Shock
COMPENSATORY:
Body employing Hyperventilation Release of adrenaline

physiological mechanisms NEUROHORMONAL BIO CHEMICAL

and noradrenaline CUSHING REFLEX

Stages of Shock
PROGRESSIVE OR DECOMPENSATING:
Sodium ions build up Potassium ions leak out Sludging of micro Prolonged

vasoconstriction Reduced perfusion

circulation

Stages of Shock
REFRACTORY/ IRREVERSIBLE:
Vital organs have failed Brain damage

Imminent death
ATP degraded to adenosine

HYPOVOLEMIC SHOCK
Most common

Insufficient circulating volume (intravascular bed)

Lack of oxygenated blood

HYPOVOLEMIC SHOCK: CAUSES

ABSOLUTE & DIRECT LOSSES GI status Haemorrhage Plasma losses Renal losses RELATIVE & INDIRECT LOSSES Hemothorax Sepsis Rupture of spleen or liver

HYPOVOLEMIC SHOCK: PATHOPHYSIOLOGY

HYPOVOLEMIC SHOCK: CLINICAL MANIFESTATIONS

Altered mental state Hypotension Rapid, weak ,thready Hypothermia Thirs, dry mouth Fatigue Cutis marmorata Pupil dilation Distracted look

pulse Cool, clammy skin Rapid, shallow respirations

HYPOVOLEMIC SHOCK: MANAGEMENT

Keep MAP equal or VASOPRESSORS: Dopamine

greater to 60 mmHg MAP= Systolic BP + 2 (Diastolic BP)/3 Crystalloids Colloids

Levophed

Never position in trendelenburg !

THREE TO ONE RULE Blood transfusion

SEPTIC SHOCK
Overwhelming systemic infection

Gram negative or positive bacteria

Endotoxin release producing biochemical and

immunological effects

SEPTIC SHOCK: PATHOPHYSIOLOGY

Microbial infection Multi organ failure

DEATH

Toxins released

Fever Hypotension Pulmonary edema Decreased coronary and renal perfusion

Mediator released

Vasodilation Edema Leukocytosis Coagulation

SEPTIC SHOCK: MANAGEMENT

Airway (oxygenation, intubation, ventilation)

Spot checking/pulse oximeter

Antibiotic therapy Obtain cultures

Fluid support
LABORATORY MONITORING Trace elements, vitamins and glucose are added

NEUROGENIC SHOCK
Spinal shock

Rarest form of shock

Trauma to spinal cord T 6 and above spinal cord should be WOF!

NEUROGENIC SHOCK: Pathophysiology

NEUROGENIC SHOCK: CLINICAL MANIFESTATIONS

Bradycardia

Decreased cardiac output

Decreased PAP and PCWP Decreased SVR

Hypotension
Hypothermia

NEUROGENIC SHOCK: MANAGEMENT

Improve tissue perfusion

Atropine Sulfate
Transcutaneous pacemaker Volume replacement

Vasopressors
Oxygenation Artificial Ventilation

CARDIOGENIC SHOCK
Inadequate pumping of blood to body tissues

Cellular destruction

CARDIOGENIC SHOCK: PATHOPHYSIOLOGY

Caused by heart attack (MI)damaging to 40 % of

ventricles

CARDIOGENIC SHOCK: MANIFESTATIONS

Hypotension less than 90 mmHg

Weak and thready pulse

PVCs in ECG tracing Chest pain and tigthness

Lung and diffused crackles

Dropping of O2 saturation Nausea

CARDIOGENIC SHOCK: MANAGEMENT

Thrombolytic therapy Angioplasty LVAD and IABP Pharmacologic Intervention Dopamine Dobutamine Norepinephrine Milrinone Sodium Nitroprusside Nitroglycerin Diuretics

OBSTRUCTIVE SHOCK
Similar to hypovolemic shock but in addition: Distended jugular veins Pulsus paradoxus

ANAPHYLAXIS & ANAPHYLACTOID REACTION

Life threatening hypersensitivity/pseudoallergic

reaction
IMMUNE MEDIATED CHEMICALLY MEDIATED

ANAPHYLAXIS
Antigen-antibody

reactionallergies Foods, environmental agents, medications, blood products, etc can trigger an immune mediated reaction. IgE 1st exposure- Primary immune response 2nd exposure- release of chemical mediators causing vasodilatation, increased capillary permeability & smooth muscle contraction

Slow reacting substance of

anaphylaxis (SRS-A) Eosinophilic chemotactic factor of anaphylaxis (ECF-A) Platelet activating factors (PAF) Kinins Prostaglandins

ANAPHYLACTOID REACTION
May occur without prior to exposure to a drug

Self limiting within 5 to 10 minutes

ANAPHYLAXIS & ANAPHYLACTOID REACTION: MANIFESTATIONS

Pruritus Generalized erythema Urticaria Angioedema Restlesness, giddiness w/ Laryngeal edema Bronchoconstriction Pulmonary edema Dizziness Altered state of

complaint of a sense of impending doom Vomiting Diarrhea Cramping Abdominal pain

consciousness Tachycardia Arrythmias Decreased SVR

ANAPHYLAXIS & ANAPHYLACTOID REACTION: MANAGEMENT

Discontinue causative WOF severe laryngeal

agent Administer Epinephrine (Adrenaline) @ 0.3 to 0.5 ml dosage

Production of cyclic

edema Albuterol inhalation Anti-histamines Corticosteroids

adenosine monophospate (cAMP) ABCs