Академический Документы
Профессиональный Документы
Культура Документы
Dr Anuj Raj
Bijukchhe
Introduction
Definition of shock
Types of shock
Causes of shock
Signs and symptoms of shock
Body’s response to shock
Treatment of shock
Definition of Shock
• 1. Initial
• 2. Compensatory.
• 3. Progressive
• 4. Refractory
• An initial non progressive stage- during which
reflex compensatory mechanisms are activated
and perfusion of vital organ is maintained.
• A progressive stage - characterized by
tissue hypo perfusion and onset of worsening
circulatory and metabolic imbalance.
• An irreversible stage - that sets in after the
body has incurred cellular & tissue injury so
severe that even if the hemodynamic defect are
corrected , survival is not possible.
Mechanism of
microcirculatory disorder
of shock
9
The stages and mechanisms of
microcirculatory disorder of shock
Stagnant hypoxia
stage
Microcirculation failure
stage
10
Ischemic hypoxia stage
• Compensatory mechanism
Blood pressure Pulse pressure Blood flow Blood volume
angiotensinogen
Baroreceptors
chemoreceptors
Adrenal cortex
Vasomotor centre Adrenal medulla
Angiotensin ı
Venous
capacitance Circulating systemic
Volume resistance
Heart rate
Myocardial contractility Maintain venous return
Anaerobic metabolism
lactate
In>out
Stagnation of blood
Capillary pressure
Capilary leak
12
Blood pressure
microcirculation
Arteriolar and precapillary Precapillary sphincter constrict
sphincter
Microcirculatio
n Fluid from outer to vascular compartment
perfusion
Ischemic hypoxia
Of microcirculation
13
DIC and MODS
Stagnation of blood
Ischemic hypoxia
of
microcirculatio
n
Injury of endothelium
DIC
SIRS
MODS
14
Classification by causes
• Hypovolemic shock
• Traumatic shock
• Burn shock
• septic shock
• Cardiogenic shock
• Anaphylactic shock
• Neurogenic shock
15
Classification by
pathophysiological changes
• Hypovolemic shock
• Cardiogenic shock
• Obstructive shock
• Distributive shock
16
Hypovolemic shock
• Hemorrhage
• Burns
• Diarrhea
• Vomiting
• Peritonitis
Cardiogenic
• Pulmonary Embolism
• Cardiomyopathy
• Heart Disease
• Cardiac Contusion
• Cardiac Tamponade
• Myocardial Infarction Arrhythmia
• Aortic Aneurys
Vasogenic
• Psychogenic
• Anaphylactic
• Septic
Hypovolemic Shock
• Septic Shock
Hyperdynamic
Hypodynamic
• Toxic Shock
• Neurogenic Shock
• Psychogenic Shock
Septic Shock vs. SIRS
• Fever
• Chills
• Sweating
• Altered mental status
Apprehension
Anxiety
Agitation
• Some localizing symptoms
Head and neck infections - earache, sore throat,
sinus pain or congestion, nasal congestion or exudate,
swollen lymph glands
• Chest and pulmonary infections - cough (especially if
productive), pleuritic chest pain, dyspnea
• Abdominal and GI infections - abdominal pain,
nausea, vomiting, diarrhea
• Pelvic and genitourinary infections - pelvic or flank
pain,
vaginal or urethral discharge, dysuria, frequency,
urgency
• Bone and soft tissue infections - focal pain or
tenderness, focal erythema , edema
Septic shock
Similar to hypovolaemic shock except in the first
stages Pyrexia , due to increased level
of cytokines
• Systemic vasodilation resulting in hypotension
• Warm and sweaty skin due to vasodilation
• Systemic leukocyte adhesion to endothelial tissue
• Reduced contractility of the heart
• Diffuse capillary damage in the lung
• Activation of the coagulation pathways, resulting
in disseminated intravascular coagulation
• Increased levels of neutrophils
Neurogenic shock
• Neurogenic shock is the rarest form of shock.
It is caused by trauma to the spinal cord
resulting in the sudden loss
of autonomic and motor reflexes below the
injury level. Without stimulation
by sympathetic nervous system the vessel
walls relax uncontrolled, resulting in a sudden
decrease in peripheral vascular resistance ,
leading to vasodilation and hypotension .
Neurogenic shock,
49
Common manifestations
• Tachycardia, oliguria, a clouded
sensorium, cool mottled extremities
indicative of reduced blood flow to
the organ.
• Metabolic acidosis ,often due to
elevated blood lactate levels, reflects
prolonged inadequate blood flow to
tissues.
50
Specific manifestations
• Hypovolemic shock:have a history of
gastrointestinal bleeding
,hemorrhage,or diarrhea,vomitting
• Cardiogenic shock : have signs of
heart disease,gallop rhythms
• Distributive shock: localized infection
as well as fever and chills
51
Manifestations
Cardiovascular system
Early Lately
•
Blood pressure N or ↓ ↓↓
• Heart rate N or ↑ ↑↑
• Cardiac output N or min↑ ↓↓
52
Manifestations
Cardiovascular system
53
Manifestations
renal system
54
Manifestations
repiratory system
• Early Lately
• Tachypnoea Tachypnoea
• Laboured breathing
• Central cyanosis
55
Manifestations
Gastrointestinal system
56
Organ dysfunction
• Heart mechanism
• Respiratory failure
Acute lung injury and acute respiratory distress
syndrome(ARDS) are menifested as non cardiogenic
pulmonary edema resulted from diffuse pulmonary
capillary endothelial and alveolar epithelial
injury,hypoxia,and bilateral diffuse pulmonary
infiltrates.
58
Organ dysfunction
59
Organ dysfunction
• Acute renal failure early stage
61
Diagonsis of shock
• Step 1 look: investigating the patient’s
skin and facial expression;
• Step 2 inquire: inquiring the history and
know if his/her sense is clear;
• Step 3 touching: touching the patient’s
pulse to know its intensity 、 speed and
rhythm, and touching the temperature and
humidity of the skin;
• Step 4 listen: listening to the heart sound
and measuring the blood pressure.
62
Diagonsis
• Manifestation: Dysfunctional signs of
each organ,
BP increase ,heart rate increase
compensatory stage
BP decrease, heart rate increase
decompensatory stage
63
Diagnostic standard by
stages
• Early stage:
Mechanism:Activation of sympathetic nerve
and release of catecholamine.
Symptom: Pale ,cool and damp extremities;
normal consciousness with agitation ,decreased
urine output ,normal or a little decreased BP,
Pulse pressure <20mmHg,SBP decreased more
than 40mmHg if the patient has hypertension
before.
64
Diagnostic standard by
stages
• Middle stage:
Symptom: Normal consciousness
but with a slow response, thirsty for
water , thready pulse, Trachypnoea ,
urine output<20ml/h , SBP 60~80mmHg.
65
Diagnostic standard by
stages
• End stage:
Symptom: Confusion or coma , cool
mottled or pale skins or cyanotic
extremities, peripheral pulses become
thready or may be absent;SBP <60mmHg or
can not be measured, anuria , Tachypnoea,
tendency of DIC, manifestation of acidosis.
66
Shock monitoring
1. Normal index
2. Invasive hemodynamic monitoring
3. Function of oxidative metabolism
4. Laboratory monitoring
67
Normal index
• Mental status:
• Vital signs: Temperature, heart rate ,
breath rate, blood pressure
• Colour and temperature of the skin
• Shock index: pulse rate/SBP
> 1.0-1.5 indicate shock;
>2.0 severe shock
• Urine output <25ml/h indicate inadequate tissue
perfusion;
>30ml/h indicate shock corrected 68
Invasive hemodynamic
monitoring
69
Invasive hemodynamic monitoring
• By Swan-Ganz catheter
• PCWP :(pulmonary capillary wedge
pressure) PCWP is similar to the pressure
of left atria
PCWP<12mmHg indicate hypovolemia,
12 - 15mmHg indicate normal,
>15mmHg indicate hypervolemia or left
heart failure
• CO and CI :CO 4 ~ 6L/min, CI 2.5~3.5L/
(min.m2) CO=heart rate ×stroke
volume ,CI=CO/body area
70
Function of oxidative metabolism
• Sp02 > 90% simple and noninvasive
• Arterial blood gas analysis
• PaO2 80 ~ 100mmHg;
PaCO2 35 ~ 45mmHg ;
PH 7.35 ~ 7.45;
HCO3- 22-27mmol/L
● Lactic acid monitoring
lactic acid >2mmol/L
71
Laboratory monitoring
• Blood routine :Red blood cell count,
hemoglobin, and Hematocrit
• Electrolyte and renal function :K ,Na,Ca,
Serum creatinine
• DIC:
Tendency of bleeding clinically
APTT>normal index +3 seconds
Number of platelet < 80×109/L or decline
gradually
Fg<1.5g/L or gradually decreased
73
Treatment
The aim of therapy is to improve the
supply of oxygenated blood to the
tissues.
74
Principle of treatment
1. Normal treatment
2. Aetiology treatment
3. Restore normal blood volume
4. Provision of adequate oxygenation
5. vasoactive drugs
6. Correct acidosis, electrolyte disturbance
7. Glucocorticoids therapy
8. Prevention of DIC
9. Protect function of organs,prevention of
MODS
75
Normal treatment
• Body posture: lay flat or the legs are elevated by 30 。
Keep body calm and warm
• Keep the respiratory tract smoothly , clear away
respiratory secretions in time. supply oxygen by nasal
catheter, mask, mechanical ventilation or endotracheal
intubation. oxygen flow
• Set up Venous access as early as possible. subclavian
vein, Jugular vein, Femoral vein catheterization for the
purpose of fluid infusion .CVP
• conscious-sedation , alleviate pain : if the patient is
agitated. proper treatment.
• Shock monitoring.
76
Restore normal blood
volume
• Restoration of optimal circulating blood volume
• Fluid infusion is a most important therapeutic measure
in the treatment of shock, whether it is the initial cause
of shock ,or a complication of cardiogenic , distributive
or obstructive shock. the velocity of liquid can be very
fast , the kind of liquid can be colloids or crystalloids
.But The volume and speed of administration depends
on the patient’s cardiac competence and must be
considered carefully if acute left ventricular failure and
the resultant pulmonary edema are to be avoided.
77
Treatment
83
Provision of adequate
oxygenation
• All patients who are clinically shocked
should be given supplementary oxygen.
• Lung is an organ injured most easily in
shock,manifested as respiratory failure ,or
with shock goes on ,patient lay in coma.
we can take endotracheal intubation to
maintain the respiratory function by
mechanical ventilation.
84
Provision of adequate
oxygenation
• Mechanical ventilation is required if
oxygenation remains
inadequate,i.e.a PaO2 < 60mmHg or
if respiratory acidosis develops,i.e. a
PaCO2 > 60mmHg.
85
86
To prevent the risks of oxygen toxicity , the
inspired oxygen concentration should be
limited to 60% or less.The PaO2 should be
kept at about 100mmHg and PaCO2 about
40mmHg. The addition of positive end
expiratory pressure(peep),up to 15
cmH2O,should be used if higher
concentrations of oxygen appear to be
necessary 。
87
vasoactive drugs
• vasoconstrictor :High-output and low-resistance
Dopamine
Dobutamine
Noradrenaline
Adrenaline
Cardiac stimulant
• Vasodilatator :Low-output and high-resistance
Nitroprusside sodium
Phentolamine
Glycerol trinitrate
88
Correct acidosis,electrolyte
disturbance
• lactic acidosis is most common in metabolic acidosis
.metabolic acidosis decrease the myocardial
contractility,increase the resistance of pulmonary and
renal circulation,decrease the affinity of Hb for O2
• cardiogenic shock and hypovolemic acidosis :deal
with etiological factor and volume resuscitation;
5%sodium bicarbonate ivgtt by ABGA
pH<7 . 20 。
• Septic shock:deal with acidosis actively.
89
Glucocorticocids therapy
Glucocorticocids :
Mechanism :
Anti-shock ,anti-toxin ,anti-
inflammatory response, anti-
anaphylaxis,stabilize cell membrane .
Inhibit release of inflammatory
mediators.It can be used in all kinds of
shock.
90
Prevention of DIC give heparin in early
stage.
Protect function of organs,
prevention of MODS.especially
acute renal failure.
91
Distributive shock
95