haemorrhagic shock and mx
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APPROACH TO THEPATIENT IN SHOCK ANDIT’S MANAGEMENT
(HAEMORRHAGE)
FOO HONG ZHI
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Defnition
Shock is circulatory insufciency thatcreates an imbaance bet!een tissueoxygen supply "#ei$er%& an# oxygendemand "cons'm(tion&)
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Defnition "cont)&
Car#iacInotro(%* s(ee# an# shortenin+ ca(acit%o, m%ocar#i'm-
Chronotro(%* heart contraction rate- an#.'sitro(%* abiit% to rea/ an# f heartchambers
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Ho! is o'r bo#% res(onse toshock0
Shock acti$ates autonomic responses- man%o, !hich ser$e to maintain (er,'sion (ress're to$ita or+ans) Stim'ation o, the caroti#
barorece(tor stretch re1e/ acti$ates thes%m(athetic ner$o's s%stem ea#in+ to*
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Ho! is o'r bo#% res(onse to shock0 "cont)&
2) Arterioar $asoconstriction- res'tin+ inre#istrib'tion o, boo# 1o! ,rom the skin-skeeta m'sce- ki#ne%s- an# s(anchnic $iscera3
4) An increase in heart rate an# contractiit% thatincreases CO3
5) Constriction o, $eno's ca(acitance $esses-!hich a'+ments $eno's ret'rn3
6) Reease o, the $asoacti$e hormonese(ine(hrine- nore(ine(hrine- #o(amine- an#
cortiso to increase arterioar an# $eno's tone3an#
7) Reease o, ADH an# acti$ation o, the renin8an+iotensin a/is to enhance !ater an# so#i'm
conser$ation to maintain intra$asc'ar $o'me)
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Ho! is o'r bo#% res(onse to shock0 "cont)&
The ce'ar res(onse to shock initiates acasca#e o, (athoo+ic e$ents that res't in
hemoconcentration-
h%(erkaemia-
h%(onatremia-
Prerena a9otemia-
h%(er8 or h%(o+%cemia-
actic aci#osis)
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Cassifcation o, shock
H%(o$oaemicCar#io+enic
Obstr'cti$e
Distrib'ti$eEn#ocrine
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Cassifcation o, shock "cont)&
HypovolaemicA re#'ce# cic'atin+ $o'meHaemorha+ic or non haemorha+ic "#eh%#ration-e/cessi$e 1'i# oss in #iarrho(ea or $omitin+- 'rinar%oss in #iabetes- e$a(oration an# thir# s(ace&
Car#io+enicPrimar% ,ai're o, the heart to ('m( boo# to thetiss'eMI- #%srh%tmias- $a$'ar heart #isease- b'ntm%ocar#ia in:'r%- an# car#iom%o(ath%
Obstr'cti$eRe#'ction in (reoa# beca'se o, obstr'ction o,car#iac fin+Car#iac tam(ona#e- tension (ne'mothora/-
massi$e ('monar% emboism- air emboism)
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Cassifcation o, shock "cont)&
Distrib'ti$e
The (attern o, car#io$asc'ar res(onsescharacteri9in+ a $ariet% o, con#ition inc'#in+*se(tic shock- ana(h%a/is- s(ina cor# in:'r%)
Ina#e;'ate or+an (er,'sion is accom(anie# b%$asc'ar #iatation !ith h%(otension- o! s%stemic$asc'ar resistance- ina#e;'ate a,teroa# an# ares'tin+ abnorma% hi+h car#iac o't('t)
En#ocrine
Combination o, h%(o$oaemic- car#io+enic an##istrib'ti$e shock)
H%(o<h%(erth%roi#ism- a#rena ins'=cienc%
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Car#io$asc'ar an# metaboiccharacteristics o, shock
Hypovalaemia
Cardiogenic
Obstructive
Distributive
CO .o! .o! .o! Hi+h
>asc'ar
resistance
Hi+h Hi+h Hi+h .o!
>eno's(ress're
.o! Hi+h Hi+h .o!
Mi/e# $eno'ssat'ration
.o! .o! .o! Hi+h
?ase #efcit Hi+h Hi+h Hi+h Hi+h
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Conse;'ences o, Shock
1. Unresuscitatable shock Pro,o'n# shock ,or a (roon+e# (erio# o, time)Ce #eath ,rom ce'ar ischaemia- an# the abiit%
o, the bo#% to com(ensate is ost)M%ocar#ia #e(ression- not res(onse to 1'i# or
inotro(ic thera(%- (eri(hera% oss abiit% tomaintain s%stemic $asc'ar resistance) Death isine$itabe)
2. ulti!organ "ailure2 or more ,aie# or+an s%stems) S'((orti$e care).'n+s* ARDSKi#ne%* AKI.i$er* Ac'te i$er ins'=cienc%Coa+'o(ath%Car#iac ,ai're
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Haemorrha+e
#o recognise$ to manage a++ressi$e%to re#'ce the se$erit% an# #'ration o,shock an# a$oi# #eath an#<or m'ti(eor+an ,ai're)
Haemorrha+e is treate# b% arrestingthe bleeding- an# not b% 1'i#res'scitation or boo# trans,'sion)
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Patho(h%sioo+%
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Defnitions%evealed haemorrhage* ob$io's e/terna haemorrha+e)
E+ e/an+'ination ,rom an o(en arteria !o'n# or massi$ehaematemesis ,rom #'#ena 'cer)
Concealed haemorrhage is containe# !ithin the bo#%ca$it% an# m'st be s's(ecte#- acti$e% in$esti+ate# an#controe#)
&rimary haemorrha+e* imme#iate% as a res't o, an in:'r%)
%eactionary haemorrha+e* #ea%e# haemorrha+e "!ithin46 ho'rs& an# is 's'a% ca'se# b% #iso#+ement o, cot b%res'scitation- normai9ation o, ?P an# $aso#iatation)
'econdary haemorrha+e* is ca'se# b% so'+hin+ o, the!a o, a $esse- occ'rs @826 #a%s a,ter in:'r% an# is(reci(itate# b% ,actors s'ch as in,ection- (ress're necrosis"#rain& or mai+nanc%)
'urgical haemorrhage is the res't o, a #irect in:'r% an#is amenabe to s'r+ica contro)
(on!surgical haemorrhage is the +enera oo9e ,rom ara! s'r,aces #'e to coa+'o(ath%- it cannot be sto((e# b%
s'r+ica means "e/ce(t (ackin+& b't re;'ires correction o,coa+'ation abnormaities)
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Cassifcation o, Haemorrha+ic shockC)*'' + C)*'' ++ C)*'' +++ C)*'' +,
?oo# oss
- m.
B27-
B@7
2785-
@7827
586-
2784
6-
4
?P 'nchan+e# Norma-raise#
%educed >er% o! orrecor#abe
HR< PR norma #achycardia
1--!12-
tach%car#ia
24
tach%car#ia24
CRT norma so! so! 'n#etecte#
RR norma norma tach%(noeic
tach%(noeic
rineo't('tM<ho'r
5 485 284 82
E/tremitie norma (ae (ae Pae an# co#
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Mana+ement
AIRFA- s(ine stabii9ation an# ?REATHING*HM- i, s(ontaneo's $entiation nota#e;'ate- int'bation an# $entiation isnee#e#)
CIRC.ATION an# sec're bee#in+*4 I> access "orJ& to c'bita ,ossa or ,emora
$eins
?P- HR- CRT- menta stat's- 'rine o't('t
I#entife# haemorrha+e
Haemorrha+e contro* Dama+e contro s'r+er%
DISA?I.IT* GCS- ('(is
EPOSRE an# co$er
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Mana+ement "cont)&
Histor% takin+Aer+ies
Me#ications
Past me#ica histor%.ast mea
E$ents s'rro'n#in+ in:'r%
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Permissi$e H%(otension
L Aso kno!n as hypotensive resuscitationis the 'se o, restricti$e 1'i# thera(%s(ecifca% in the tra'ma (atient- thatincreases S?P !itho't reachin+
normotension)L To achie$e '& /-!0-mmHg "s'=cient to
maintain critica or+an (er,'sion& in non8T?I)
L Res'scitatin+ JmmH+ r'ns the risk o,cot #iso#+ement an# $icio's circe,ormation)
L Transient res(on#er or non8res(on#er
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'i# res'scitation
L There is no #ierence in s'r$i$a com(arin+ cr%staoi#
!ith cooi# res'scitation)L Cr%staoi# so'tions remain recommen#e# beca'se o,
the increase# cost o, cooi# a+ents)L Isotonic cr%staoi# so'tions- norma saine "NS&- or
actate# Rin+er’s ".R& so'tion are the (re,erre#
res'scitation 1'i#s)L Cr%staoi# so'tions are h%(o8oncotic) .o! oncotic
(ress're res'ts in s'bstantia shi,ts o, cr%staoi# to thee/tra$asc'ar s(ace corres(on#in+ to the reati$e si9e o,the intra$asc'ar an# interstitia 1'i# com(artments)
L 1 ratio "or isotonic crystalloid volumereplacementL "or every amount o" blood lost$ three times that
amount o" isotonic crystalloid is re3uired to storeintravascular volume because$ at best$ about -4o" the in"used 5uid stays intravascular
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?oo# trans,'sion
In#ications*LAc'te boo# oss- to re(ace circ'atin+$o'me an# maintain o4 #eman#)
LPerio(erati$e anaemia- to ens'rea#e;'ate o4 #ei$er% #'rin+ (erio(erati$e(hase)
LS%m(tomatic chronic anaemia !itho'thaemorrha+e or im(en#in+ s'r+er%)
LO ne+ati$e- sa,e O
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Scenario 2
L A 67 %ear o# +enteman com(aint*Im (assin+ back stoo !ith boo# an#i+hthea#e#ness ,or 5 #a%s)
A((roach in emer+enc% settin+)
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Scenario 2 "cont)&
L O<E* aert- orientate#- o$er!ei+ht mae-
an/io's an# restessL ?P 24<- HR 22<min- RR 4- T 5@
L acia (aor- coo moist skin- :a'n#ice-
fn+er c'bbin+- coate# ton+'e
L .'n+s cear- C>S s%stoic m'rm'r ataortic area
L Ab#omen #isten#e# !ith #iate# $ein-#i=c't to eicit he(atos(enome+a%-1'i# tris (ositi$e) H%(eracti$e bo!e)
L PR* maaenae !ith ,resh boo#)
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