SHOCK SHOCK Aayed Al-Qahtani, FRCSC, FACS Aayed Al-Qahtani, FRCSC, FACS Ass. Prof. & Consultant Ass. Prof. & Consultant Department of Surgery Department of Surgery Division of Pediatric Surgery Division of Pediatric Surgery College of medicine College of medicine KSU KSU
44
Embed
SHOCK Aayed Al-Qahtani, FRCSC, FACS Ass. Prof. & Consultant Department of Surgery Division of Pediatric Surgery College of medicine KSU.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Ass. Prof. & Consultant Ass. Prof. & Consultant Department of SurgeryDepartment of Surgery
Division of Pediatric SurgeryDivision of Pediatric SurgeryCollege of medicineCollege of medicine
KSUKSU
To understand Physiology of sustaining blood To understand Physiology of sustaining blood pressurepressure
To learn about the classifications of shockTo learn about the classifications of shock
To understand the consequences of the natural To understand the consequences of the natural history of shockhistory of shock
To be able to diagnose and plan appropriate To be able to diagnose and plan appropriate treatments for different types of shocktreatments for different types of shock
2. May be primary event (cardiogenic shock) or due 2. May be primary event (cardiogenic shock) or due to to decreased myocardial perfusion due to shock from decreased myocardial perfusion due to shock from
other causesother causes
Heart rate Heart rate
Initial tachycardia (attempt to increase CO)Initial tachycardia (attempt to increase CO)
Rhythm Rhythm Regular and tachycardicRegular and tachycardic
GI tractGI tract Failure of intestinal barrier (sepsis, bleeding)Failure of intestinal barrier (sepsis, bleeding)
LungLungCapillary leak associated with or caused by sepsis and Capillary leak associated with or caused by sepsis and infection (ARDS = adult respiratory distress syndrome)infection (ARDS = adult respiratory distress syndrome)
HEMODYNAMIC RESPONSE TO SHOCKHEMODYNAMIC RESPONSE TO SHOCKMechanisms for restoring cardiovascular homeostasisMechanisms for restoring cardiovascular homeostasis
Redistribution of blood flow Redistribution of blood flow Attempt to preserve perfusion to vital organsAttempt to preserve perfusion to vital organs
Augmentation of cardiac outputAugmentation of cardiac outputIncreased heart rateIncreased heart rateIncreased peripheral resistanceIncreased peripheral resistance
Restoration of intravascular volumeRestoration of intravascular volume
SEPTIC SHOCKSEPTIC SHOCKSEVERE INFECTION W RELEASE OF
MICROBIAL PRODUCTSRelease of vasoactive mediators
HYPERDYNAMIC STATEPeripheral vasodilation
Increased cardiac output
Fever, tachycardia, tachypnea, warm skin
MAINTENANCE OF INTRAVASCULAR VOLUME
Hyperdynamic shock
FAILURE TO MAINTAIN INTRAVASCULAR VOLUME
Hypodynamic shock
Cool skin, tachycardia, hypotension, oliguria
Systemic Inflammatory Response Syndrome (SIRS)
The patients demonstrate a similar response as sepsis but without infective agents.
The criteria are : (two or more to call it SIRS) Temperature >38 or < 36 Heart rate >90 RR > 20 or a pco2 < 34 mmHg (4.3 kpa) WBC > 12,000 0r < 4,000 with more than 10% bands
Neurogenic Shock
It is a shock that result from a high spinal cord injury ( e.g Cervical spine injury)
This will result in loss of sympathetic tone Loss of sympathetic tone will result in:
Arterial and venous dilatation causing hypotension. Bradycardia as a result of unopposed vagal tone.
The typical feature is hypotension with bradycardia
Management of neurogenic shock
Assessment of airway Stabilization of the entire spine Volume resuscitation R/O other causes of shock High dose corticosteroids.
PRINCIPLES OF PRINCIPLES OF RESUSCITATIONRESUSCITATION
SUMMARYSUMMARY Shock is an altered state of tissue Shock is an altered state of tissue
perfusion severe enough to induce perfusion severe enough to induce derangements in normal cellular functionderangements in normal cellular function
Neuroendocrine, hemodynamic and Neuroendocrine, hemodynamic and metabolic changes work together to metabolic changes work together to restore perfusionrestore perfusion
Shock has many causes and often may be Shock has many causes and often may be diagnosed using simple clinical indicatorsdiagnosed using simple clinical indicators
Treatment of shock is primarily focused Treatment of shock is primarily focused on restoring tissue perfusion and oxygen on restoring tissue perfusion and oxygen delivery while eliminating the causedelivery while eliminating the cause
10 yo female10 yo female
Fell off bike riding down a hill. Initially well but 4 Fell off bike riding down a hill. Initially well but 4 hrs later complained of abd pain and L shoulder hrs later complained of abd pain and L shoulder painpain
VS: BP 90/60, P 120 (tachycardic), RR 30 VS: BP 90/60, P 120 (tachycardic), RR 30 (tachypneic), T 100.1, O(tachypneic), T 100.1, O22 sat 95% (low) sat 95% (low)
GEN: pale, anxiousGEN: pale, anxious
LUNG: clear to auscultationLUNG: clear to auscultation
COR: tachycardic with murmur best at baseCOR: tachycardic with murmur best at base
ABD: diffuse tenderness w/o peritonitis or massABD: diffuse tenderness w/o peritonitis or mass
Hb 7.5 (low)Hb 7.5 (low)
CASE PRESENTATION CASE PRESENTATION CIRCULATORY SHOCKCIRCULATORY SHOCK
ABD CT:ABD CT: splenic laceration with free peritoneal fluid splenic laceration with free peritoneal fluid
TimeTime
% % survivasurviva
ll
Fast rateFast rate
Slow rateSlow rate
NoneNone
ResuscitationResuscitation
RESUSCITATIONRESUSCITATIONNEED FOR SPEEDNEED FOR SPEED
17 yo male17 yo male
Diving into waterDiving into water
VS: BP 90/60 (low), P 110 (high), RR 24 (high)VS: BP 90/60 (low), P 110 (high), RR 24 (high)
CASE PRESENTATIONCASE PRESENTATIONCAPILLARY LEAKCAPILLARY LEAK
DX:DX: 60% TBSA burn 60% TBSA burn
HYPOVOLEMIC SHOCK (LOSS OF FLUID INTO INTERSTITIUM)HYPOVOLEMIC SHOCK (LOSS OF FLUID INTO INTERSTITIUM)
10 yo female10 yo female
Fell off bike riding down a hill. Initially well but 4 Fell off bike riding down a hill. Initially well but 4 hrs later complained of abd pain and L shoulder hrs later complained of abd pain and L shoulder painpain
VS: BP 90/60, P 120 (tachycardic), RR 30 VS: BP 90/60, P 120 (tachycardic), RR 30 (tachypneic), T 100.1, O(tachypneic), T 100.1, O22 sat 95% (low) sat 95% (low)
GEN: pale, anxiousGEN: pale, anxious
COR: tachycardic with murmur best at baseCOR: tachycardic with murmur best at base
ABD: diffuse tenderness w/o peritonitis or massABD: diffuse tenderness w/o peritonitis or mass
CASE PRESENTATION CASE PRESENTATION CIRCULATORY SHOCKCIRCULATORY SHOCK
• Circulatory shockCritical reduction in tissue perfusionResults in organ dysfunction and, if not treated, deathUsually accompanied by signs and symptoms:
OliguriaMental status changesWeak thready pulseCool clammy limbs
• Septic shockHypotensionVasodilatation with warm limbs.
OVERVIEWOVERVIEWGENERIC CLASSIFICATIONS OF SHOCKGENERIC CLASSIFICATIONS OF SHOCK