SHOCK. Intensive care of shock. Extreme conditions. Cardio –pulmonari resustication.

1. SHOCK. Intensive care of shock. Extreme conditions. Cardio –pulmonari resustication. L.Yu.Ivashchuk

2. Outline • Definition • Epidemiology • Physiology • Classes of Shock • Clinical Presentation • Management • Controversies

4. Definition • A physiologic state characterized by • Inadequate tissue perfusion • Clinically manifested by • Hemodynamic disturbances • Organ dysfunction

5. Epidemiology • Mortality • Septic shock – 35-40% (1 month mortality) • Cardiogenic shock – 60-90% • Hypovolemic shock – variable/mechanism

6. Pathophysiology • Imbalance in oxygen supply and demand • Conversion from aerobic to anaerobic metabolism • Appropriate and inappropriate metabolic and physiologic responses

7. Pathophysiology • Cellular physiology • Cell membrane ion pump dysfunction • Leakage of intracellular contents into the extracellular space • Intracellular pH dysregulation • Resultant systemic physiology • Cell death and end organ dysfunction • MSOF and death

8. Physiology • Characterized by three stages • Preshock (warm shock, compensated shock) • Shock • End organ dysfunction

9. Physiology • Compensated shock • Low preload shock – tachycardia, vasoconstriction, mildly decreased BP • Low afterload (distributive) shock – peripheral vasodilation, hyperdynamic state

10. Pathophysiology • Shock • Initial signs of end organ dysfunction • Tachycardia • Tachypnea • Metabolic acidosis • Oliguria • Cool and clammy skin

11. Physiology • End Organ Dysfunction • Progressive irreversible dysfunction • Oliguria or anuria • Progressive acidosis and decreased CO • Agitation, obtundation, and coma • Patient death

12. Classification • Schemes are designed to simplify complex physiology • Major classes of shock • Hypovolemic • Cardiogenic • Distributive

13. Hypovolemic Shock • Results from decreased preload • Etiologic classes • Hemorrhage - e.g. trauma, GI bleed, ruptured aneurysm • Fluid loss - e.g. diarrhea, vomiting, burns, third spacing, iatrogenic

16. Hypovolemic Shock • Hemorrhagic Shock Crit Care. 2004; 8(5): 373–381.

17. Cardiogenic Shock • Results from pump failure • Decreased systolic function • Resultant decreased cardiac output • Etiologic categories • Myopathic • Arrhythmic • Mechanical • Extracardiac (obstructive)

18. Distributive Shock • Results from a severe decrease in SVR • Vasodilation reduces afterload • May be associated with increased CO • Etiologic categories • Sepsis • Neurogenic / spinal • Other (next page)

20. Distributive Shock • Other causes • Systemic inflammation – pancreatitis, burns • Toxic shock syndrome • Anaphylaxis and anaphylactoid reactions • Toxin reactions – drugs, transfusions • Addisonian crisis • Myxedema coma

21. Distributive Shock • Septic Shock

22. Clinical Presentation • Clinical presentation varies with type and cause, but there are features in common • Hypotension (SBP<90 or Delta>40) • Cool, clammy skin (exceptions – early distributive, terminal shock) • Oliguria • Change in mental status • Metabolic acidosis

23. Evaluation • Done in parallel with treatment! • H&P – helpful to distinguish type of shock • Full laboratory evaluation (including H&H, cardiac enzymes, ABG) • Basic studies – CxR, EKG, UA • Basic monitoring – VS, UOP, CVP, A-line • Imaging if appropriate – FAST, CT • Echo vs. PA catheterization • CO, PAS/PAD/PAW, SVR, SvO2

24. Treatment • Manage the emergency • Determine the underlying cause • Definitive management or support

25. Manage the Emergency • Your patient is in extremis – tachycardic, hypotensive, obtunded • How long do you have to manage this? • Suggests that many things must be done at once • Draw in ancillary staff for support! • What must be done?

26. Manage the Emergency • One person runs the code! • Control airway and breathing • Maximize oxygen delivery • Place lines, tubes, and monitors • Get and run IVF on a pressure bag • Get and run blood (if appropriate) • Get and hang pressors • Call your senior/fellow/attending

27. Determine the Cause • Often obvious based on history • Trauma most often hypovolemic (hemorrhagic) • Postoperative most often hypovolemic (hemorrhagic or third spacing) • Debilitated hospitalized pts most often septic • Must evaluate all pts for risk factors for MI and consider cardiogenic • Consider distributive (spinal) shock in trauma

28. Determine the Cause • What if you’re wrong? • 85 y/o M 4 hours postop S/P sigmoid resection for perforated diverticulitis is hypotensive on a monitored bed at 70/40 • Likely causes • Best actions for the first 5 minutes?

29. Definitive Management • Hypovolemic – Fluid resuscitate (blood or crystalloid) and control ongoing loss • Cardiogenic - Restore blood pressure (chemical and mechanical) and prevent ongoing cardiac death • Distributive – Fluid resuscitate, pressors for maintenance, immediate abx/surgical control for infection, steroids for adrenocortical insufficiency

30. Controversies • IVF Resuscitation • Limited resuscitation in penetrating trauma • Use of hypertonic saline resuscitation in trauma • Endpoints for prolonged resuscitation • Pressors • Best pressors for distributive shock • Monitoring • Most appropriate timing and use for PA catheterization or intermittent echocardiogram

31. Three stages of ABC-reanimation. Algorithm of its realization by one and two medical men. Testimony to defibrillation and technique of its execution. Cardiac shock of feature of clinical dynamics, first aid. Acute respiratory insufficiency. Reasons of origin, types of hypoxia, degrees of heaviness. Medicinal therapy. Treatment of post-reanimating illness.

32. First aid at the terminal states. • Concept about the terminal states, purpose and task the first medical aid, first-aid and medical rescue.

33. General principles, legal, organizational, medical and deontological features of giving the first aid in extraordinary situation. Algorithm of primary inspection of the patient in the place of event.

34. BASIC CONCEPTS in REANIMATOLOGY • Reanimatology is science about the revival of organism, which studies etiology, pathogenesis, diagnostics and treatment of the terminal states. • A reanimation (abroad widespread is a term of rescucitation) is a process of replacement and proceeding in the functions of organism by the leadthrough of the special reanimation measures. It is proposed by V.Negovsky (1975). To these measures a pneumocardial reanimation belongs in particular (CLR).

35. Clinical death -| it is the state which circulation of blood and spontaneous breathing absent in the conditions of, but there yet were irrecurent changes in the human brain, when it is yet possible to return a patient to life without a clinically meaningful neurological deficit.

36. Why does attention apply exactly on a cerebrum? It is a structure of organism, which most sensible to the hypoxia or anoxia (clinical death), and in tissue of which above all things in case of stopping of circulation of blood there are irreversible changes. Maximally this period can last 3-б min, except of some states, above all things hypothermias, when vitability of cortex can be restored and through the greater interval of time.

37. Biological death is consisting of irreversible changes above all things of CNS, when to life turning a man is impossible. To the clinical signs of biological death take drying out and dimness of cornea, of a corpse spots and of a corpse.

38. Such concepts utillize in rescucitation, as a decortication (social death) is death of cortex (when somatic functions can recommence almost in full, but the function of cortex does not recommence) a that decerebration is death of cerebrum. • By the clinical signs of decortication ñ absence of свідо­мості and purchased reflexes. There is a timber-toe by the dead bark of the brain on condition of valuable supervision can live yet long time. To set the exact diagnosis of decortication heavily, as there are events, when after the protracted comma a man came to consciousness.

39. A decerebration arises up after more protracted total ischemia of brain (20 min and anymore), sometimes can develop on a background a decortication in the case of progress of іschemical-reperfusion defeats.

40. The clinical signs of death of cerebrum is absence of electric activity of cerebrum during ЕЕG-decay, atony, areflexy, hypothermia, bradicardia, arterial hypotension, absence of the independent breathing. The vital functions of organism at decerebrationmay be supported of short duration time due to the leadthrough of AB and support of circulation of blood. Such organism can be utillized as a donor for transplantation of organs.

41. On condition of primary stop of circulation of blood the spontaneous rhythmic breathing stopping is not later than in 1 min as a result of exhaustion of respiratory center. But the terminal types of breathing are possible: Cheyn-Stoks, Biott, breathing by Husping. • After the stop of heart a man loses consciousness already through 10-15 sdue to exhaustion of power substrates in the brain, first of all glucosum.

42. MOST WIDESPREAD REASONS OF UNEFFECTIVE CIRCULATION OF BLOOD MYOCARDIAC ISCHEMIA A myocardial ischemia more frequent all arises up as a result of violation of circulation of blood in coronarias (embolism, spasm). The extreme display of ischemia is a sharp heart attack of myocardium. As a result of complete absence of delivery oxygen there is a sharp deficit of power substrates to cardiac cells, above all things ATP.

43. Activity of cells membrane pumps and canals, foremost Na+, K+ and Ca++ is violated. The result of it is an accumulation in the myocardium Na and Ca with development of intracellular edema, there is a considerable intracellular deficit of K+. The finished goods of metabolism accumulate in myocardium, foremost C02 and lactat which results in heavy intracellular acidosis.

44. It does not follow to forget that the damage of cardiac cells (and also tissues of brain and other tissues of an organism) takes a place and after proceeding in perfusion, is the so-called syndrome of reperfusion. Its damaging factors are active free radicals (above all things, oxygen – super-oxides, peroxides, ions of hydroxide, peroxinitrate) on a background diminishing of activity of the antioxidant system.

45. Reflex stop of heart • Takes a place foremost as a result of n.vagus reflexes (from an eye is reflex of Ashner, trachea, carotis areas, root of lights, stomach, uterus). It should be noted that usually the stop of cardiac activity arises up on a background a myocardial ischemia, intact myocardium in default of hypoxia (it can be respiratory hypoxia, ischemia and others like that) quickly «avoids» influence of n.vagus.