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SHOCK

SHOCK CAUSES AND MANAGEMENT DEFINITION Condition in which arterial blood flow/perfusion (Blood Pressure) is inadequate to meet tissue metabolic needs(maintain normal funtion of vital organs) In a healthy adult : Hypotension – arterial BP<90mmHg Shock – arterial BP <60mmHg

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SHOCK

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  1. SHOCK CAUSES AND MANAGEMENT

  2. DEFINITION Condition in which arterial blood flow/perfusion (Blood Pressure) is inadequate to meet tissue metabolic needs(maintain normal funtion of vital organs) In a healthy adult : Hypotension – arterial BP<90mmHg Shock – arterial BP <60mmHg Postural Hypotension- Drop in Systolic BP of 10-20mmHg or increase in Pulse rate of >15 with position change indicates hypovolemia

  3. DIFFERENTIAL DIAGNOSIS OF SHOCK • HYPOVOLEMIA • CARDIAC PUMP FAILURE • OBSTRUCTIVE • DISTRUBUTIVE - SYSTEMIC VASODILATATION GET HISTORY FROM RELATIVES

  4. HYPOVOLEMIA

  5. SYMPTOMS & SIGNS OF HYPOVOLEMIA – Blood Loss in a 70kg patient circulating blood volume is 5 liters (approx 70 ml/kg) Loss of Blood 15% (700-750 ml)- may produce little or no obvious symptoms 30% (1500ml) –mild tachycardia, tachpnoea and anxiety 30-40%-(1750ml) tachycardia (110-120beats per min) & marked hypotension 40% (2000ml) is life threatening Plasma-5%body wt=3,500 ml Interstitial Fluid- 15% body wt = 10,500ml Intracellular volume= 40% body wt= 28,000ml

  6. Hypovolemia from Diarrhoea/Vomiting- loss of water & lytes • Thirsty • Passes small amounts yellow urine • Dizzy on sitting (postural hypotension – 5% body wt loss =3500 ml Shock – 10% = 7000ml • Dry axilla & groin ( 1500ml water deficit) • Decreased tissue turgor- tongue has furrows,skin folds on pinching it , sunken eyeballs • Cool clammy extremities • Tachycardia • Weak or absent pulses • Empty neck veins in the supine position

  7. Cardiogenic –Cardiac Pump Failure Myocardial Infarction Cardiomyopathy Dysrhythmia     Tachyarrhythmia     Bradyarrhythmia Acute valvular dysfunction (especially regurgitant lesions) Rupture of ventricular septum or free ventricular wall

  8. SIGNS & SYMPTOMS OFSHOCK PRODUCED BY PUMP FALURE HEART FAILURE • Sudden onset in VT/VFib • Chest pain in MI • Absent heart sounds or severe tachycardia • Raised JVP • Pedal oedema • Basal lung rales • Hepatojugular reflux

  9. Obstructive shock -Decrease in Cardiac Filling Tension pneumothorax Disease of pulmonary vasculature (massive pulmonary emboli, pulmonary hypertension)   Pericardial disease (tamponade, constriction)   Cardiac tumor (atrial myxoma)   Left atrial mural thrombus   Obstructive valvular disease (aortic or mitral stenosis)

  10. SYMPTOMS OF OBSTRUCTIVE SHOCK Raised JVP- • Tension pneumothorax- absent breath sounds • Cardiac tamponade- distant heart sounds • Cardiogenic shock • Pulmonary embolism- chest pain, dyspnoea,hemoptysis,swollen calf, h/o immobilisation • Fluid overload

  11. Distributive shockDecrease in Systemic Vascular Resistance - Vasodilatation Septic shock   Anaphylactic shock,   Neurogenic shock   Acute adrenal insufficiency Vasodilator drugs

  12. Signs & Symptoms of Septic Shock Usually gram-bacteria (E.coli,Kleb,Pseuo,Prot.) Fever with chills, confusion, hyperglycemia in old/babies, diabetes, immunosuppressed, H/o recent surgery/manipuation of urinary,biliary,gynae system

  13. S&S ANAPHYLAXIS History of • Atopy • Insect bite esp wasp/bees • Food (peanuts, fish, eggs, seafood), • Drugs (penicillin, blood products, iron inj, aspirin, NSAIDS, vaccines Urticaria, Oedema of skin and mucous membranes (angioedema), Wheezing- bronchospasm Stridor- laryngeal oedema Generalised itching, rhinitis, conjuntival redness

  14. Neurogenic Shock Causes– spinal cord injury, spinal anaesthesia, vasovagal- pain/fright-h/ofainting,bradycardia,

  15. ASSESSMENT OF SHOCK PATIENT Pt in Cardiac Arrest- call for help Moniter- V fib –shock V tach- vagal manoeuvers- carotid sinus massage Adenosine-6mg iv fast followed by 5 ml saline flush Rpt in 1-2 min 12mg Flat line- CPR

  16. ASSESSMENT OF SHOCK PATIENT Check airway- clear of blood/vomitus Start O2 or intubate if unconscious Auscultate lungs for air entry absent- tension pneumothorax / hemothorax? (percussion) rales – cardiac failure? rhonchi- anapyhlaxis? LVFailure Auscultate heart- distant sounds- cardiac tamponade? Murmurs- acute valve problems? JVP flat- hypovolemia distended- cardiac failure?, PE,,Ten PT,,Cardiav Tamp? Abdomen- Fullness or pulsatile mass( ruptured aneurysm?) Tender – pancreatitis, perforation?

  17. ASSESSMENT OF SHOCK PATIENT BP on both arms- different –dissection of aorta Fever- sepsis Pt cold clammy- hypovolemia? Cardiac failure? Hypovolemia signs- skin/tongue turgor, sunken eyeballs,pallor Pedal oedema- cardiac failure Blood around mouth, malena? ( do PR) Urticaria, wheals, soft tissue swelling (anaphylaxis)

  18. ASSESSMENT OF SHOCK PATIENT Investigations ABG ECG CXR Blood tests-Hb,WBC,platelets, Lytes,Blood sugar Creatinine,LFT, PT,PTT,Grouping & xmatch Cultures- Blood,urine,sputum ECHO Ultrasound abd , CT head

  19. TREATMENT- HYPOVOLEMIADiarrhoea. Vomiting Insert 2 IV canulae (16 guage)-forearm, groin, central line Cut down Head down position Infuse normal saline or ringers lactate- replace ½ the loss Insert Urinary catheter(Foley)- 1ml/kg Keep assesssing – dec IV when BP >90 and pt urinating

  20. TREATMENT OF Heart Failure Myocardial Infarction MONA Dopamine

  21. Treatment of Pneumothorax Insert chest tube in 2nd intercostal space in midclavicular line Heimlich valve

  22. Treatment of Sepsis Antibiotics Correct cause of sepsis IV Fluids-leaky capillaries

  23. Treatment of Anaphylaxis Airway- O2 mask/ intubate, / cricothyroidotomy with 14 guage canula or small ET tube Head down IV line Adrenaline 0.5 ml of 1:1000 soln IM or 5ml of 1:10,000 soln IV(0.1ml /kg body wt in children) slowly at 1ml/min till Bp recorded rpt every 10min acc to BP/pulse Hydrocortisone- 100-300mg IV H1 blocker- antihistamine- promethazine 25-50mg IV Rpt 4-6hrly Aminophylline IV for bronchospasm (250mg IV)

  24. DOPAMINE Acts on diff receptors at diff doses Low dose- ( 0.5-2 microgm/kg/min) D1 on vascular smooth muscle causes vasodilatation of renal, mesenteric, cerebral, coronary vascular bed Mod dose (2-5 microgm/kg/min) Beta1 receptors- positive ionotropic and chronotropic High dose - > 5 microgm/kg/min) Alpha receptors- vasoconstiction and decrease blood flow

  25. Hemodynamic calculations CVP- = R atrial pressure = 1-7 mm Hg Pulm art pressure 15-30/3-12 mmHg PAWP= Pulm artery wedge pressure=3-12 mm Hg Cardiac index = cardiac output 4-6 l/min Body surface area =2.8-3.6l/min/sq.m ( sp gr of Hg=13.7)

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