SHOCK-SHOCK SYNDROME, CARDIOGENIC SHOCK,HYPOVOLEMIC,ANAPHYL-ACTIC,NEUROGENIC,SEPTIC SHOCK.

SHOCK-SHOCK SYNDROME, CARDIOGENIC SHOCK,HYPOVOLEMIC,ANAPHYL-ACTIC,NEUROGENIC,SEPTIC SHOCK.1SHOCK:

Shock occurs when the blood pressure is too low to sustain a supply of oxygen and nutrients; and to remove waste products from body cells, tissues and organs. It may be hypovolaemic, cardiogenic, distributive or obstructive.shock is defined as a condition where the tissues in the body don't receive enough oxygen and nutrients to allow the cells to function. This ultimately leads to cellular death, progressing to organ failure and finally, to whole body failure and death.

2STAGES OF SHOCK:

There are four stages of shock. Initialstage:Compensatory (Compensating)stage:Progressive (Decompensating)Refractory (Irreversible)

3SHOCK SYNDROME:

Toxic shock syndrome (TSS) is a life-threatening condition caused by toxins produced by certain types of infecting bacteria. The condition has been most often associated with the use of tampons in menstruating women. Although this outbreak was linked to toxins produced by the Staphylococcus aureus bacteria, TSS can also be caused by toxins from the group A Streptococcus bacteria. The condition is sometimes subdivided and referred to as staphylococcal TSS and streptococcal TSS.TSS can occur as a complication of surgery or skin infections.

4Risk factors :use of tampons barrier contraceptive devices in women, surgery (especially nasal surgery), the use of wound packings (such as nasal packings), and postoperative wound infection. Signs and symptoms :few days of mild flu-like symptoms before the TSS develops, but TSS itself is characterized by the rapid onset of specific symptoms, including high fever, nausea, vomiting, diarrhea, low blood pressure, and widespread skin rash. This will usually progress to a worsening of low blood pressure, dizziness, confusion, peeling of the skin of the palms and soles of the feet (which develops after one to two weeks of rash), headaches, and occasionally seizures. Ultimately, multiorgan failure may develop, and this leads to death in approximately 5 % of all those affected.

5Diagnosis:thorough physical examination (which includes a pelvic examination in women), blood tests -white blood cell count (to look for signs of infection), blood cultures (evaluating for possible bacteria in the bloodstream) and evaluation of kidney and liver function. Blood tests to exclude other diseases may also be ordered.Chest X-rays or CT scans of the abdomen or pelvis

6MANAGEMENT:Foreign material such as tampons, contraceptive devices, or wound packings must be immediately removed. Treatment may involve a combination of the following:intravenous (IV) fluids to stabilize the blood pressure, possibly in combination with medications to raise blood pressure;IV antibiotics to fight the source of the infection;oxygen administration;removal of tampons, nasal packings, or other suspected sources of the infection;surgical interventions to drain the source of the infectiondialysis if kidney failure develops.Other therapiesIV immunoglobulin has been reported to be beneficial in severe cases of TSS.

7CARDIOGENIC SHOCK:

Cardiogenic shock is a physiologic state in which inadequate tissue perfusion results from cardiac dysfunction. Hemodynamic criteria for cardiogenic shock are sustained hypotension (systolic blood pressure 40%) Symptoms include the following: marked tachycardia, decreased systolic BP, narrowed pulse pressure (or immeasurable diastolic pressure), markedly decreased (or no) urinary output, depressed mental status (or loss of consciousness), and cold and pale skin. This amount of hemorrhage is immediately life threatening.21Imaging Studiesultrasonographic examination - if an abdominal aortic aneurysm is suspected. If GI bleeding is suspected, a nasogastric tube should be placed, and gastric lavage should be performed. An upright chest radiograph should be obtained if a perforated ulcer is a possibility. Endoscopy can be performed (usually after the patient has been admitted) to further delineate the source of bleeding. A pregnancy test should be performed in all female patients of childbearing age. Computed tomography (CT) scanning typically is performed in the stable patient. If long-bone fractures are suspected, radiographs should be obtained.

22Prehospital Care

Direct pressure should be applied to external bleeding vessels to prevent further blood loss.The cervical spine must be immobilized.Splinting of fractures can minimize further neurovascular injury and blood loss. securing an adequate airway, ensuring ventilation, and maximizing circulation. use of military antishock trousers (MAST).

23Emergency management:

Three goals: (1) maximize oxygen delivery - completed by ensuring adequacy of ventilation, increasing oxygen saturation of the blood, and restoring blood flow, (2) control further blood loss, and (3) fluid resuscitation.

24Maximizing oxygen delivery

Two large-bore IV lines should be started. Once IV access is obtained, initial fluid resuscitation is performed with an isotonic crystalloid, such as lactated Ringer solution or normal saline. If vital signs return to normal, the patient may be monitored to ensure stability, and blood should be sent for typed and cross-matchedThe position of the patient can be used to improve circulation; one example is raising the hypotensive patient's legs while fluid is being given. Autotransfusion may be a possibility in some patients with trauma. COMPLICATIONS: Neurologic sequelae , Death

25ANAPHYLATIC REACTION:

Anaphylaxis is a severe allergic reaction that occurs rapidly and causes a life-threatening response involving the whole body. This reaction can lead to difficulty breathing and shock ultimately leading to death.Greek words ana (against) and phylaxis (protection). For an anaphylactic reaction to occur, a patient must have been exposed in the past to the substance that causes the reaction, called the antigen. This is call ed "sensitization." A bee sting, for example, may not cause an allergic reaction the first time. These reactions usually occur within seconds to minutes of exposure. Occasionally, they are delayed.

26CLASSIFICATION:

"true anaphylaxis" and "pseudo-anaphylaxis" or "anaphylactoid reaction."true" anaphylaxis is caused by degranulation of mast cells or basophils mediated by immunoglobulin E (IgE), and pseudo-anaphylaxis occurs without IgE mediationBiphasic anaphylaxisBiphasic anaphylaxis is the recurrence of symptoms within 72 hours with no further exposure to the allergen. Anaphylactic shockAnaphylactic shock is anaphylaxis associated with systemic vasodilation which results in low blood pressure. It is also associated with severe bronchoconstriction .

27PseudoanaphylaxisIt however does not involve an allergic reaction but is due to direct mast cell degranulation. This can result from morphine, radiocontrast, aspirin and muscle relaxants. Active anaphylaxisActive anaphylaxis is what is naturally observed. After Two weeks, is exposed to certain allergens, active anaphylaxis (which is simply called "anaphylaxis") would be elicited upon exposure to the same allergens.

28ETIOLOGY:

Prescription and over-the-counter medicationsVenom of stinging insectsTransfusion of blood or blood productsNumerous other substances such as latex (natural rubber)Dyes and contrast materials used during radiologic procedures or testsSometimes the trigger of the reaction is obvious--a bee sting, or a new prescription drug. Often, however, the trigger is unknown.People with asthma, eczema, or hay fever are slightly more likely to have an anaphylactic reaction than people who do not have these conditions.

29Any two or more of the following symptoms within minutes to several hours of allergen exposure: a. Involvement of the skin or mucosa b. Respiratory difficulties c. Low blood pressure d. Gastrointestinal symptoms Prevention:The greatest success with prevention of anaphylaxis has been the use of allergy injections to prevent recurrence of sting allergy.

30Septic shock

Septic shock is a serious medical condition caused by decreased tissue perfusion and oxygen delivery as a result of infection and sepsis, though the microbe may be systemic or localized to a particular site. It can cause multiple organ dysfunction syndrome (formerly known as multiple organ failure) and death. To diagnose septic shock, the following two criteria must be met:Evidence of infection, which may include a positive blood cultureRefractory hypotension - hypotension despite adequate fluid resuscitation and cardiac output.

31In addition to the two criteria, two or more of the following must be present:Tachypnea (high respiratory rate) > 20 breaths per minute or, on blood gas, a less than 32 mmHg of PCO2White blood cell count < 4000 cells/mm or > 12000 cells/mmHeart rate > 90 beats per minuteTemperature > 38.0C (100.4F) or < 36.0C (96.8F)cold peripheries and increased capillary refilling time

32ETIOLOGY:

When microorganisms get into the blood stream, it produces a condition known as bacteremia. If the organisms are particularly virulent, or the host is immunocompromised, then the host organism may develop a condition known as systemic inflammatory response syndrome (or SIRS). Sepsis is bacteremia, combined with SIRS.Origin of infection Respiratory tract infection and urinary tract infection are the most frequent causes of sepsis, followed by abdominal and soft tissue infections.The use of intravascular devices is a notorious cause of nosocomially-acquired sepsis.

33Soft tissue infections are the cause of septic shock in 15% of patients, and the following are the common pathogens: S aureusStaphylococcus epidermidisStreptococciClostridiaGram-negative bacteriaAnaerobesGI tract infections are the cause of septic shock in 15% all patients, and the following are the common pathogens: E coliStreptococcus faecalisBacteroides fragilisAcinetobacter speciesPseudomonas speciesEnterobacter speciesSalmonella species

34Microorganisms: Lower respiratory tract infections are the cause of septic shock in 25% of patients. The following are common pathogens: Streptococcus pneumoniaeKlebsiella pneumoniaeStaphylococcus aureusEscherichia coliLegionella speciesHaemophilus speciesAnaerobesGram-negative bacteriaFungiUrinary tract infections are the cause of septic shock in 25% of patients, and the following are the common pathogens: E coliProteus speciesKlebsiella speciesPseudomonas speciesEnterobacter speciesSerratia species

35Foreign bodies leading to infections are the cause of septic shock in 5% of patients, and S aureus, S epidermidis, and fungi/yeasts (Candida species) are the common pathogens.Miscellaneous infections are the cause of septic shock in 5% of patients, and Neisseria meningitidis is the common pathogen.Anaerobic pathogens are becoming less important as a cause of sepsis. Fungal infections are the cause of sepsis in 0.8-10.2% of patients with sepsis, and their incidence appears to be increasing.

36Risk factors for severe sepsis and septic shock

Extremes of age ( 70 y)Primary diseases Liver cirrhosisAlcoholismDiabetes mellitusCardiopulmonary diseasesSolid malignancyHematologic malignancyImmunosuppression NeutropeniaImmunosuppressive therapyCorticosteroid therapyIntravenous drug abuseCompliment deficienciesAsplenia

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Risk factors

Major surgery, trauma, burnsInvasive procedures CathetersIntravascular devicesProsthetic devicesHemodialysis and peritoneal dialysis cathetersEndotracheal tubesPrior antibiotic treatmentProlonged hospitalizationOther factors - Childbirth, abortion, and malnutrition

38Pathophysiology:

39American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM)Sepsis: This is a systemic inflammatory response to a documented infection. The clinical features include 2 or more of the following conditions as a result of a documented infection:Rectal temperature greater than 38C or less than 36CTachycardia (>90 bpm)Tachypnea (>20 breaths per min)With sepsis, at least 1 of the following manifestations of inadequate organ function/perfusion also must be included:Alteration in mental stateHypoxemia (PaO2 -6Indicates acid production secondary to hypoxia.\56BLOOD CULTURESGrowth of organismsIn case of septic shock.LACTATEIncreasedUsually increases once significant hypo perfusion and impaired oxygen utilization at cellular level have occurred. By product to of anaerobic metabolism.LIVER ENZYMES (ALT, AST, GGT)IncreasedElevations indicate liver cell destruction in progressive state of shock.URINESPECIFIC GRAVITYIncreased Fixed at 1.010.Occurs secondary to the action of ADH.In renal failure.57DRUGMECHANISM OF ACTIONTYPE OF SHOCKDobutamineIncrease myocardial contractilityDecrease ventricular filling pressureUsed in Cardiogenic shock with severe systolic dysfunction.Used in septic shock with normal CO that is not meeting increased metabolic demands.DopaminePrecursor to epinephrine and nor epinephrine, Hemodynamic effects from release of nor epinephrine.Positive inotropic effects:Increased myocardial contractilityIncreased automaticityIncreased atrioventricular conductionCardiogenic shock58EpinephrineLOW DOSES; adrenergic agonist (cardiac stimulation, bronchial dilatation, peripheral vasodilation)High doses: adrenergic agonist(peripheral vasoconstriction)Cardiogenic shock combined with afterload reduction.Anaphylactic shock Cardiac arrest, pulseless ventricular tachycardiaVentricular fibrillationaystoleNor epinephrine 1- adrenergic agonist (cardiac stimulation) adrenergic agonist(peripheral vasoconstriction)renal /splanchnic vasoconstrictionCardiogenic shock after myocardial infarctionSeptic shock : works by increasing vascular tone.59Phenyl ephrine adrenergic agonistVasoconstriction: renal, mesenteric, splanchnic, cutaneous, and pulmonary vessels.neurogenic shockNitroglycerinVenodilationCardiogenic shockSodium nitroprusside.Arterial and venous vasodilatation.Cardiogenic shock with increased SVR.60FLUID THERAPY IN SHOCK:

Crystalloids: Isotonic: 0.9% NACL, Ringer lactateBlood and blood products: Whole blood /packed red blood cells.Colloids Hetastarch, Human serum albumin ,Dextran

61NURSING MANAGEMENTDecreased cardiac output related to blood loss, impaired fluid distribution, impaired circulation, inadequate heart contraction, massive vasodilation.Impaired gas exchange related to reduced cardiac output secondary to blood loss, heart failure, altered body fluid distribution, vasodilation, and bradycardia.Hypothermia related to haemerrahgeIneffective tissue perfusion related to hypovolemia or inadequate cardiac output or inadequate vascular tone.defecient knowledge related to unfamiliar condition of shock.62COMPLICATINS OF SHOCKCENTRAL NERVOUS SYSTEM- neurological defeicits.CARDIOVASCULAR SYSTEM- cardiac failureHEMATOLOGICAL SYSTEM- DICRESPIRATORY SYSTEM- acute respiratory distress syndrome.RENAL SYSTEM- acute renal failureHEPATIC SYSTEM-coagulopathyGI- Ischemia and ulceration.63THANK YOU64