SHOCK. SHOCK DEFINTION The common denominator in all forms of shock is inadequate capillary perfusion. Shock is Characterized by Inadequate Tissue Perfusion

SHOCK SHOCK

SHOCK DEFINTIONSHOCK DEFINTIONThe common denominator in all forms The common denominator in all forms of shock is inadequate capillary of shock is inadequate capillary perfusion.perfusion.

Shock is Characterized by Inadequate Shock is Characterized by Inadequate Tissue Perfusion and Cellular Tissue Perfusion and Cellular Hypofunction/Hypoxia.Hypofunction/Hypoxia.

Total body celular metabolism is Total body celular metabolism is malfunctional, usually by inadequate malfunctional, usually by inadequate delivery of oxyden to meet celluar needs delivery of oxyden to meet celluar needs and occasionally of inability of cells to and occasionally of inability of cells to utilize oxygene( methemoglobinemia, utilize oxygene( methemoglobinemia, carbon monooxide poisoning).carbon monooxide poisoning).

SHOCKSHOCK

shock has been recognised for over shock has been recognised for over 100 years, a clear definition is not 100 years, a clear definition is not estabilished till this momentestabilished till this moment, t, the he definition of shock varies from time definition of shock varies from time to time and has different meanings to time and has different meanings according to the etiological and according to the etiological and pathogenetic factors, what caused it.pathogenetic factors, what caused it.

Classified by EtiologyClassified by Etiologyby by Mark A. Graber, MD:Departments of Family Medicine and Mark A. Graber, MD:Departments of Family Medicine and

Emergency Medicine University of Iowa College of MedicineEmergency Medicine University of Iowa College of Medicine Peer Peer Review Status: Externally Peer Reviewed by MosbyReview Status: Externally Peer Reviewed by Mosby

Hypovolemic shockHypovolemic shock from volume loss from volume loss (e.g., dehydration, blood loss, burns) (e.g., dehydration, blood loss, burns)

Distributive shockDistributive shock based on loss based on loss of vascular tone (e.g., anaphylactic, of vascular tone (e.g., anaphylactic, septic, bacteremic, toxic, septic, bacteremic, toxic, neurogenic shock).neurogenic shock).

Classified by EtiologyClassified by Etiologyby by Mark A. Graber, MD:Departments of Family Medicine and Mark A. Graber, MD:Departments of Family Medicine and

Emergency Medicine University of Iowa College of MedicineEmergency Medicine University of Iowa College of Medicine Peer Peer Review Status: Externally Peer Reviewed by MosbyReview Status: Externally Peer Reviewed by Mosby

Cardiogenic shockCardiogenic shock based on pump based on pump failurefailure( acute myocardial infarction, ventricular ( acute myocardial infarction, ventricular septal defect rupture, papillar muscles rupture, septal defect rupture, papillar muscles rupture, ventricular aneurysm, severe aortic stenosis, ventricular aneurysm, severe aortic stenosis, arrhythmias, trauma- tensione pneumothorax, arrhythmias, trauma- tensione pneumothorax, pericardial temponade, cardic contusionpericardial temponade, cardic contusion

Dissociative shockDissociative shock based on inability based on inability of RBC to deliver oxygen of RBC to deliver oxygen

(e.g., methemoglobinemia, carbon monoxide (e.g., methemoglobinemia, carbon monoxide posoning). posoning).

Most common clinical Most common clinical signs:signs:

Hypotension. Blood pressure Hypotension. Blood pressure drop is a late findingdrop is a late finding. . An orthostatic systolic decrease of 10 to 20 An orthostatic systolic decrease of 10 to 20

mm Hg or increase in pulse of 15 beats/min mm Hg or increase in pulse of 15 beats/min is considered "significant." is considered "significant."

Take orthostatic vital signs recumbent and Take orthostatic vital signs recumbent and after standing for 1 to 2 minutes. * after standing for 1 to 2 minutes. * Orthostatic vital signs may be normal in Orthostatic vital signs may be normal in hypovolemic individuals, or nor-mal hypovolemic individuals, or nor-mal individuals may exhibit orthostatic individuals may exhibit orthostatic changes; so use clinical judgment and base changes; so use clinical judgment and base treatment on symptoms. Alcohol ingestion, treatment on symptoms. Alcohol ingestion, a meal, increased age, antihypertensives, a meal, increased age, antihypertensives, etc. may cause orthostatic changes in BP etc. may cause orthostatic changes in BP and pulse in the absence of hypovolemia.and pulse in the absence of hypovolemia.


Tachycardia usually present Tachycardia usually present but may not be, especially in but may not be, especially in the presence of the presence of diaphragmatic irritation, diaphragmatic irritation, which causes vagal which causes vagal stimulation, in neurogenic stimulation, in neurogenic shock. shock.


Hypoperfusion including decreased Hypoperfusion including decreased urine output, decreased mentation, urine output, decreased mentation, cool extremities, mottling, etc.cool extremities, mottling, etc.* * Goal of resuscitation is to maintain urine output Goal of resuscitation is to maintain urine output between 30 and 60 ml/hr. between 30 and 60 ml/hr.

Hypovolemic shockHypovolemic shock

DefinitionDefinition

It is present when marked It is present when marked reduction in oxygen delivery reduction in oxygen delivery results from diminished cardiac results from diminished cardiac output secondary to inadequate output secondary to inadequate volume of wholevolume of whole blood. blood.


The main causes are:The main causes are: - external bleeding;- external bleeding; - internal bleeding;- internal bleeding; - the loss of big amount of plasma due to - the loss of big amount of plasma due to

wide burns;wide burns; - the loss of liquids and electrolytes after - the loss of liquids and electrolytes after

long lasting and hard diarrhea, vomiting;long lasting and hard diarrhea, vomiting; - an internal loss of liquids due to pleuritis - an internal loss of liquids due to pleuritis

of peritonitis, acute pancreatitis.of peritonitis, acute pancreatitis.* three last sometimes nemed as oligemic shock* three last sometimes nemed as oligemic shock


Pathophysiology: Pathophysiology:

diminishing cardiac output or diminishing cardiac output or fluid flow secondary to fluid flow secondary to decreasing venous returndecreasing venous return


Clinicla signs:Clinicla signs:

hypotensia, tachycardia, hypotensia, tachycardia, tachypnoe, oliguria, anxious, skin tachypnoe, oliguria, anxious, skin is pale and cool, often patient is pale and cool, often patient have nausea and vomiting, can have nausea and vomiting, can be restless or comatosebe restless or comatose

Hypovolemic shockHypovolemic shock acording American Surgeons Committee of Trauma 1988acording American Surgeons Committee of Trauma 1988

Clinical signsClinical signs I classI class II calssII calss III classIII class IV classIV class

Blood lossBlood loss <750<750 750-1500750-1500 1500-20001500-2000 2000>2000>

Blood loss%Blood loss% <15<15 15-3015-30 30-4030-40 40>40>

Puls ratePuls rate <100<100 >100>100 >120>120 140>140>

APAP NormalNormal NormalNormal DecreasedDecreased DecreasedDecreased

BRBR 14-2014-20 20-3020-30 30-4030-40 >35>35

Urination(ml/h)Urination(ml/h) 30>30> 20-3020-30 5-155-15 <5<5

CNS functionCNS function A litttile anxious A litttile anxious Middle anxiousMiddle anxious Anxious or Anxious or suffocatingsuffocating

Suffocating or Suffocating or lethargiclethargic


Laboratory determination: Laboratory determination:

arterial blood gases: pH is considered normal arterial blood gases: pH is considered normal 7.35-7.45, PaCO2 – 35-45mm/ml, in pH <7.35 is 7.35-7.45, PaCO2 – 35-45mm/ml, in pH <7.35 is associated with a normal or less normal PaCO2 -associated with a normal or less normal PaCO2 -( metabolic acidosis)( metabolic acidosis)

in vomiting by stenosis of pyloric part of in vomiting by stenosis of pyloric part of ventriculus - alcalosisventriculus - alcalosis

serum electrolytes in hemorragic shock near serum electrolytes in hemorragic shock near normal, in diarhhoe K↓, vomiting Na↓, normal, in diarhhoe K↓, vomiting Na↓, pancreatitis Ca↓ ,K↓ and etc.pancreatitis Ca↓ ,K↓ and etc.

creatinine is usefule as an indicator of renal creatinine is usefule as an indicator of renal functionfunction


Treatment and menagemant of Treatment and menagemant of hypovolemic shock principles:hypovolemic shock principles:

monitoring of blood pressure, urination, monitoring of blood pressure, urination, breafing function, HRbreafing function, HR

replasment of blood volume ( Ringer lactate, replasment of blood volume ( Ringer lactate, solutions similar to plasma in electrolites solutions similar to plasma in electrolites composition, starch or gelatin solution, in composition, starch or gelatin solution, in bleading erythrocite massbleading erythrocite mass

supplemental oxygenesupplemental oxygene after resuscitation surgery manipulations, after resuscitation surgery manipulations,

interventionaly radiology, endoscopy, drugs.interventionaly radiology, endoscopy, drugs.

Distributive shock Distributive shock

septic, bacteremic shock - based septic, bacteremic shock - based on loss of vascular tone, on loss of vascular tone, bacteremia and septic shock are bacteremia and septic shock are closely related conditions.closely related conditions.


Bacteremic shockBacteremic shock develops when develops when hight amount of of bacteremia or hight amount of of bacteremia or fungs and its toxic agents penetrate fungs and its toxic agents penetrate into the blood and when the host into the blood and when the host defenses are decreased due to defenses are decreased due to prolonged and hard infectional prolonged and hard infectional illness.illness.


Septic shockSeptic shock is sepsis with is sepsis with hypoperfusion and hypotension hypoperfusion and hypotension refractory to fluid therapy.refractory to fluid therapy.

When bacteremia produces changes When bacteremia produces changes in circulation such that tissue in circulation such that tissue perfusion is critically reduced, septic perfusion is critically reduced, septic shock ensues.shock ensues.


The main causes are:The main causes are: Septic shock is more often caused by Septic shock is more often caused by

hospital-acquired hospital-acquired gram-negative bacilligram-negative bacilli and usually occurs in immunocompromised and usually occurs in immunocompromised patients and those with chronic diseases. patients and those with chronic diseases.

In about 1/3 of patients it is caused by In about 1/3 of patients it is caused by gram-gram-positive coccipositive cocci and by and by CandidaCandida organisms organisms..

Shock caused by staphylococcal toxins is Shock caused by staphylococcal toxins is called called toxic shock,toxic shock, a condition more a condition more frequently occurring in young women.frequently occurring in young women.


Predisposing factors: diabetes mellitus, Predisposing factors: diabetes mellitus, cirrhosis, leukopenic states, especially cirrhosis, leukopenic states, especially those associated with underlying neoplasms those associated with underlying neoplasms or treatment with cytotoxic agents, or treatment with cytotoxic agents,

antecedent infection in the urinary, biliary antecedent infection in the urinary, biliary or GI tracts, or GI tracts,

invasive devices- catheters, drainage tubes, invasive devices- catheters, drainage tubes, and other foreign materials and prior and other foreign materials and prior treatment with antibiotics, corticosteroids, treatment with antibiotics, corticosteroids, or ventilator devices. or ventilator devices.


Septic shock occurs more often in Septic shock occurs more often in newborns, patients > 35 yr, pregnant newborns, patients > 35 yr, pregnant women, and those seriously women, and those seriously immunocompromised by underlying immunocompromised by underlying diseases or iatrogenic complications diseases or iatrogenic complications of treatment.of treatment.


PathogenesisPathogenesis

The bacterial toxins generated by the The bacterial toxins generated by the infecting organisms trigger complex infecting organisms trigger complex immunologic reactions: a large number of immunologic reactions: a large number of mediators, including TNF, leukotrienes, mediators, including TNF, leukotrienes, lipoxygenase, histamine, bradykinin, lipoxygenase, histamine, bradykinin, serotonin, and IL-2, have been implicated in serotonin, and IL-2, have been implicated in addition to endotoxin (the lipid fraction of addition to endotoxin (the lipid fraction of the lipopolysaccharides released from the the lipopolysaccharides released from the cell wall of gram-negative enteric bacilli).cell wall of gram-negative enteric bacilli).


Warm shock:Warm shock: initially, vasodilatation initially, vasodilatation of arteries and arterioles occurs, of arteries and arterioles occurs, decreasing peripheral arterial decreasing peripheral arterial resistance with normal or increased resistance with normal or increased cardiac output even though the cardiac output even though the ejection fraction may be decreased ejection fraction may be decreased when heart rate increases. when heart rate increases.


Cold shock:Cold shock: later, cardiac output may later, cardiac output may decrease and peripheral resistance may decrease and peripheral resistance may increase. Despite increased cardiac output, increase. Despite increased cardiac output, blood flow to the capillary exchange blood flow to the capillary exchange vessels is impaired, and the delivery of vessels is impaired, and the delivery of vital substrates, especially O2, and the vital substrates, especially O2, and the removal of CO2 and waste products are removal of CO2 and waste products are decreased. This decreased organ perfusion decreased. This decreased organ perfusion particularly affects the kidneys and brain, particularly affects the kidneys and brain, and subsequently causes failure of one or and subsequently causes failure of one or more of the visceral organs. Ultimately, more of the visceral organs. Ultimately, cardiac output declines and the typical cardiac output declines and the typical features of shock appear. features of shock appear.


Clinical signs:Clinical signs: altered mental alertness, chacking chill, altered mental alertness, chacking chill,

rapid rise of body temperature, BP rapid rise of body temperature, BP decreased to < 80mm Hg , the skin is decreased to < 80mm Hg , the skin is warm (paradoxically warm extremities), warm (paradoxically warm extremities), tachycardia, tachyon, and oliguria;tachycardia, tachyon, and oliguria;

late cool, pale extremities with peripheral late cool, pale extremities with peripheral cyanosis and mottling are late signs, with cyanosis and mottling are late signs, with progression, multiorgan failure involves progression, multiorgan failure involves the kidney, lungs, and liver; disseminated the kidney, lungs, and liver; disseminated intravascular coagulation (DIC) and heart intravascular coagulation (DIC) and heart failure may also occur.failure may also occur.


Laboratory determination:Laboratory determination:

leucocytosis, with marcet shift to left, leucocytosis, with marcet shift to left, associated with a sharp decrease in associated with a sharp decrease in platelet count to <= 50,000/µL, platelet count to <= 50,000/µL, respiratory alcalosis, metabolic respiratory alcalosis, metabolic acidosis, toxic anemia, positive blood acidosis, toxic anemia, positive blood cultures.cultures.

Distributive shock - Distributive shock - ManagmentManagment

should be treated in an ICU, the following should be treated in an ICU, the following should be monitored frequently: systemic should be monitored frequently: systemic pressure, arterial and venous blood pH, pressure, arterial and venous blood pH, arterial blood gas levels, blood lactate arterial blood gas levels, blood lactate level, renal function, electrolyte levels, and level, renal function, electrolyte levels, and possibly tissue PCO2, urine output should possibly tissue PCO2, urine output should be measured, usually with an indwelling be measured, usually with an indwelling catheter, as an indication of splanchnic catheter, as an indication of splanchnic blood flow and visceral perfusion,blood flow and visceral perfusion,


the CVP or pulmonary artery the CVP or pulmonary artery pressure should be measured, and pressure should be measured, and fluid replacement should be given fluid replacement should be given until the CVP reaches 10 to 12 cm until the CVP reaches 10 to 12 cm H2O or until the pulmonary wedge H2O or until the pulmonary wedge pressure reaches 12 to 15 mm Hg,pressure reaches 12 to 15 mm Hg,


respiration should be supported with respiration should be supported with nasal O2, tracheal intubation or nasal O2, tracheal intubation or tracheostomy, and mechanical tracheostomy, and mechanical ventilation as necessary, ventilation as necessary,


parenteral antibiotics should be given after parenteral antibiotics should be given after specimens of blood, body fluids, and specimens of blood, body fluids, and wound sites have been taken for Gram wound sites have been taken for Gram stain and culture; stain and culture;

prompt empiric therapy is essential, the prompt empiric therapy is essential, the choice of an antibiotic requires an choice of an antibiotic requires an educated guess based on the results of educated guess based on the results of previous cultures from the site of the previous cultures from the site of the primary infection or on the clinical setting primary infection or on the clinical setting in which the primary infection occurred.in which the primary infection occurred.

Rare cases of shockRare cases of shock

Shock due to the hormonal Shock due to the hormonal insufficiency – gl thyroydea, insufficiency – gl thyroydea, hipofhysis and etc. (type hipofhysis and etc. (type distributive shock);distributive shock);


Neurogenic shock – hypotension Neurogenic shock – hypotension secondary to central nervous system secondary to central nervous system dysfunction, it is result of dysruption of the dysfunction, it is result of dysruption of the sympathetic nervous system (type is sympathetic nervous system (type is distributive shock). distributive shock).

The main causes are: trauma or lumbal The main causes are: trauma or lumbal ane-sthesia due to vasomotoric disfunction ane-sthesia due to vasomotoric disfunction – paralysis. It results in vaso-dilatation and – paralysis. It results in vaso-dilatation and decresed vascular resistence -> blood decresed vascular resistence -> blood insufficiency in a circulatory system.insufficiency in a circulatory system.


Neurogenic shockNeurogenic shock

The main causes are: trauma or The main causes are: trauma or lumbal ane-sthesia due to lumbal ane-sthesia due to vasomotoric disfunction – vasomotoric disfunction – paralysis. It results in vaso-paralysis. It results in vaso-dilatation and decresed vascular dilatation and decresed vascular resistence -> blood insufficiency resistence -> blood insufficiency in a circulatory system.in a circulatory system.


Shock due to the hyperergic Shock due to the hyperergic reactions - allergic reactions reactions - allergic reactions develope if the patients is develope if the patients is hypersensitive to various antigenes hypersensitive to various antigenes (type distributive shock). (type distributive shock).

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SHOCK. SHOCK DEFINTION The common denominator in all forms of shock is inadequate capillary perfusion. Shock is Characterized by Inadequate Tissue Perfusion