PATIENT IN SHOCK

DR I. K. OWUSU

What is Shock?
Shock is a physiologic state characterized by

a significant reduction of systemic tissue

perfusion, resulting in decreased oxygen delivery to the tissues. This creates an imbalance between oxygen delivery and oxygen consumption. Prolonged oxygen deprivation leads to cellular hypoxia and derangement of critical biochemical processes at the cellular level, which can progress to the systemic level and if untreated, to death.

What is Shock? contd

In shock, cardiac output may be high (sepsis) or

low (eg cardiogenic shock) The common factor is failure of tissue oxygen delivery and/or utilisation

Epidemiology
Mortality

Septic shock 35-40% (1

month mortality) Cardiogenic shock 60-90% Hypovolemic shock variable/mechanism

Effects of Shock
Cellular effects include cell

membrane ion pump dysfunction, intracellular edema, leakage of intracellular contents into the extracellular space, and inadequate regulation of intracellular pH Systemic effects include alterations in the serum pH, endothelial dysfunction, and stimulation of

Effects of Shock

contd

The effects of oxygen deprivation are initially

reversible, but rapidly become irreversible. The result is sequential cell death, end-organ damage, multi-system organ failure, and death. This highlights the importance of prompt recognition and reversal of shock

Hypovolaemic (Low-volume shock)

Occurs from excssive loss of blood or

fluid leading to circulatory instability: Heamorrhage may be internal eg upper GIT bleeding, ruptured anuerysm or external .eg bleeding from laceration Fluid loss - e.g. diarrhea, vomiting, burns, third spacing, iatrogenic

Hypovolemic Shock
Hemorrhagic Shock
Parameter Blood loss (ml) Blood loss (%) I <750 <15% II 7501500 1530% III 15002000 3040% IV >2000 >40%

Pulse rate (beats/min) Blood pressure

<100 Normal

>100 Decreased

>120 Decreased

>140 Decreased

Respiratory rate (bpm)

1420

2030

3040

>35

Urine output (ml/hour) CNS symptoms

>30 Normal

2030 Anxious

515 Confused

Negligible Lethargic

Crit Care. 2004; 8(5): 373381.

Septic Shock (Vasodilative shock)

Septic shock is brought on by

infection from certain bacteria that release a chemical mediators which affects the proper functioning of the blood vessels. Vascular tone is reduced leading to vasodilatation and pooling of blood into the vascular system.

Anaphylactic/Allergic shock (Vasodilative shock)

Anaphylactic shock occurs when

there is sudden release of histamine and other chemical mediators in response to injection of a particular foreign substance, as in the case of an insect sting or certain medications. This leads to reduction in vascular tone, vasodilatation and pooling of

Cardiogenic Shock
This results from any circumstance that severely

affects the pumping action of the heart. These include:

Acute myocardial infarction Heart failure eg from dilated cardiomyopathy

Arrythmia
Pulmonary embolism Pericardial tamponade Cardio-depressant drugs (drugs with negative

ionotopic effects), such as

Beta-blockers Calcium channel blockers

Neurogenic shock
Manifested by fainting ,

occurs when the regulating capacity of the nervous system is impaired by severe pain, profound fright, or other overwhelming stimulus.

Clinical presentation
Depends upon the severity and speed of onset of

cause and the physiologic reserve of the host Systolic BP < 90 mmHg with features of reduced organ perfusion.

Clinical Presentation
Clinical presentation varies with type and cause,

but there are features in common Hypotension (SBP<90 mmHg) Tachycardia Tachypnea Cool, clammy skin (exceptions early septic shock, terminal shock) Oliguria Change in mental status Metabolic acidosis

Assessment
Should be rapid

If patient can speak, take a brief focused history

If not, assess the patient whilst questioning

relatives

Check immediately
Airway competence

Breathing
Circulation-pulse rate, rhythm, volume &

character

Specifically examine
Peripheral perfusion, including capillary refill

Blood pressure
JVP Check the trachea The Chest Conscious level Blood sugar

Obtain the following

12-lead ECG

Chest X-ray
Arterial blood gas analysis Urgent biochemistry: BUE, glucose, Calcium FBC If sepsis is suspected, blood C/S

Treatment
Manage the emergency Determine the underlying cause Definitive management or support

Manage the emergency

Control airway and breathing Maximize oxygen delivery Establish good peripheral IV access If significant bradycardia, give atropine 0.5-1 mg IV

and refer to Cardiologist for a possible pacing If the patient is not in cardiogenic shock, Give rapid IV fluid challenge (eg normal saline) If the BP remains low (<70 mmHg) despite adequate filling and treatment of immediate reversible causes, obtain central venous access start ionotropes (eg Dobutamine) Call your resident/specialist/consultant

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

Definitive Management
Hypovolemic Fluid resuscitate (blood or

crystalloid) and control ongoing loss Cardiogenic - Restore blood pressure (chemical and mechanical) and prevent ongoing cardiac death Vasodilatory/Dilatstributive Fluid resuscitate, pressors for maintenance, immediate antibiotic control for infection, etc.