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SHOCK

IN MULTIPLE INJURY

PKI 5002

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Definition

Acute circulatory failure with inadequate tissue

perfusion resulting in generalized tissue

hypoxia.

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Homeostasis

Adequate cellularoxygenationdependson

Red celloxygenation

Oxygendeliverytoalveoli

Oxygenexchange with blood

Red celldeliverytotissues

Adequateperfusion

Bloodvolume

Cardiac output Hb levels

Distance between capillariesand cells

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Pathophysiology

Inadequatetissueperfusion causes:

Generalized cellular hypoxia

Shiftfromaerobic toanaerobic metabolism

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Aerobic Metabolism

METABOLISM

6 O2

GLUCOSE

6 CO2

6 H2O

36 ATP

HEAT (417 kcal)

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Anaerobic Metabolism

METABOLISMGLUCOSE

2 LACTIC ACID

2 ATP

HEAT (32 kcal)

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CONSEQUENCE OF ANAEROBIC

METABOLISM

Inadequate cellular

Oxygendelivery

Inadequat

eenergy

productionAnaerobic

metabolism

Lactic acid

production

Metabolic

acidosisCellDeathMetabolic

failure

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The three essential patterns of circulatory

shock

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SHOCK SYNDROMES

Hypovolaemic Shock

blood VOLUME problem

Cardiogenic Shock

blood PUMP problem

Distributive Shock

blood VESSEL problem

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Hypovolemic Shock

= Low Volume

Aetiology:

Internalorexternalfluidloss

Intracellularandextracellular compartment

Most common causes:

Haemorrhage

Dehydration (non-haemorrhagic)

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Pathophysiology Hypovolaemic Shock

Decreased intravascular volume

Decreasedvenousreturn

Decreasedventricularfilling

Decreasedstrokevolume

Decreased CO

Inadequate tissue perfusion!!!!

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Signsofseverity

Grade 1

Uptoabout 15% lossofeffective bloodvolume

(~750mlinanaverageadult whoisassumedto

havea bloodvolumeof5 liters)

Thisleadstoamildrestingtachycardia

Usually,no changesinBP,pulsepressure,orrespiratoryrateoccur.

Adelayin capillaryrefilloflongerthan 3 secondscorrespondstoavolumelossofapproximately10%.

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Cont

Grade 2

Between 15-30% lossofbloodvolume

750-1500ml amoderatetachycardia (rate >100 beatsper

minute),tachypnoea,decreaseinpulsepressure,

cool clammyskinand begintonarrow thepulse

pressure. Thetimetakenforthe capillariestorefillafter 5

secondsofpressure will beextended.

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cont

Grade 3

30 - 40% lossofeffective bloodvolume

1500 - 2000 ml the compensatorymechanisms begintofail

hypotensionandtachycardia

low urineoutput (

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cont

Grade4

At40-50% lossofbloodvolume

2000 -2500 ml

Symptomsincludethefollowing:markedtachycardia,

decreasedsystolic BP,narrowedpulsepressure (or

immeasurablediastolic pressure),markedlydecreased (or

no) urinaryoutput,depressedmentalstatus (orlossof

consciousness),and coldandpaleskin. Thisamountofhemorrhageisimmediatelylife

threatening.

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Management hypovolaemic shock

Hemorrhage control

Restorevolume

Optimizeoxygendelivery

Enough circulatingred cell

Red celloxygenation

Red celldelivery

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Fluid Resuscitation

Crystalloids

Such assodium chloride (0.9%) or

La

ctated

Ringers

solution

(Hartmann's

solution

)

Dextrosesolutions which containfree waterare

lesseffectiveatre-establishing circulatingvolume

andpromote hyperglycemia.

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cont

Colloids

Forexample,polysaccharide (Dextran),polygeline(Haemaccel),succinylated gelatin (Gelofusine) and

hetastarch (Hespan). Much moreexpensivethan crystalloidsolutions

Combination

colloidsand crystalloids

Blood Essentialinsevere hemorrhagic shock,oftenpre-

warmedandrapidlyinfused

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Cardiogenic Shock

Theimpairedabilityofthe hearttopump

blood

Pumpfailureoftherightorleftventricle

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Etiology Cardiogenic Shock

Pump Failure

Acute M I

CHF

Bradyarrhythmias

Tachyarrhythmias

Cardiomyopathy

ObstructiveObstructive

(Mechanical flow

obstruction)

Tension

pneumothorax

Pulmonaryembolism

Cardiac tamponade

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Pathophysiology Cardiogenic Shock

Decreased SVDecreased CO

DecreasedBP

Decreasedtissueperfusion!!!!

Inadequatesystolicemptying

Increased LV fillingpressure(preload)

Increased LApressure

Increasedpulmonarycapillarypressure

Pulmonaryinterstitial &intraalveolar oedema!!!!

Impaired pumping

ability of LV

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Management Cardiogenic Shock

Goals:

Treatreversible

causes

Protect ischaemicmyocardium

Improvetissue

perfusion

Treatment is aimed at :

Earlyassessment &

treatment!!!

Optimizingpump by:

Increasingmyocardial O2delivery

Maximizing CO

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DISTRIBUTIVE SHOCK

Vasogenic

Septic

Anaphylactic

Acuteadrenal

insufficiency

NeurogenicNeurogenic (Lossofsympathetic

tone)

Spinal cordinjuryabove T6

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Anaphylactic Shock

Resultsfrom widespreadsystemic allergic

reactiontoanantigen

LIFETHR

EAT

EN

ING

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Pathophysiology Anaphylactic Shock

Antigenexposure

Bodystimulatedtoproduce IgE antibodiesspecifictoantigen

drugs, bites, contrast, blood, colloid,foods,vaccines,latex

Reexposure toantigen

IgE bindstomast cellsand basophils

Causes histaminerelease

Anaphylactic response

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Anaphylactic Response

Vasodilatation

Increasedvascularpermeability

Bronchoconstriction

Increasedmucusproduction

Increasedinflammatorymediators

recruitmenttositesofantigeninteraction

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ManagementAnaphylactic Shock

Earlyrecognition,treataggressively

Stopsuspecteddrug

Maintainairway:give 100% O2 Layflat & elevatefeet IV Adrenaline

Fluidresuscitation

Antihistamines

Corticosteroids

Bronchodilators

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DIAGNOSIS OF SHOCK

Based clinicallyonthepresenceofatleast 2 offollowing4 criteria

Hypotension

SBP < 90 mmHgor

MAP < 60 mmHgor

SBPq >40 mmHgfrom baseline

Oliguria < 0.25 ml/kg/hour

Cold, clammyskinand/or cloudysensorium

Metabolic acidosis

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EXPOSURE

Exposepatient

Quick surveyfrom headtotoe

Donotforgetpatients back Logrollif? C-spineinjury

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PRIMARY SURVEY

Ask thepatientdirectly

How areyou?

Ifpatientgivesameaningfulanswer:

The brainisreasonablyfunctional

Thereisanintactairway

Ventilationisoccurring

Circulationispresent

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SECONDARY SURVEY

Further history

Head-to-toe & front-to-back examination

Lab tests:ABG, clottingstudies,andetc

X-rayeverythingthat hurts

CT scan,onlyifstable

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RESUSCITATION

ENDPOINTS

Restorationofnormalvitalsigns

Adequate Urineoutput(0.5 - 1.0 ml/kg/hr) Adequate Cardiac Index Normalizationof

OxygendeliveryDO2I Normal Serum Lactatelevels

Bloodlactate < 4mmol/l

Basedeficit-3 to +3mmol/l

CVP = 15 mmHg

These endpoints

represent normalhemodynamicparameters in

adults.