ShockShock

ShockShock: :

- - Is inadequate organ perfusionIs inadequate organ perfusion

& & tissue oxygenationtissue oxygenation

ShockShockClassificationClassification: :

A. HypovolemicA. Hypovolemic

depletion of vasualar voliumdepletion of vasualar volium

B. CardiogenicB. Cardiogenic

Intrinsic failure of the heartIntrinsic failure of the heart

C. Neurogenic ShockC. Neurogenic Shock

D. SepticD. Septic

Severe untreated sepsisSevere untreated sepsis

HypovolemicHypovolemic Shock . ( H.S ) Shock . ( H.S )

Causese of H.SCausese of H.S: .: .

- - BleedingBleeding

- - Protracted vomiting or diarrheaProtracted vomiting or diarrhea

- - Sequestration of fluid in gut lumenSequestration of fluid in gut lumen

- - Loss of plasma into injured tissuesLoss of plasma into injured tissues

( ( Burns / TraumaBurns / Trauma ) )

Compensatory mechanismCompensatory mechanism

Blood lossBlood loss

Initial vasoconstriction of cutaneusInitial vasoconstriction of cutaneus

- - muscle – visceramuscle – viscera

Preserve blood flow for kidneysPreserve blood flow for kidneys

- - Heart - BrainHeart - Brain

- - Normal blood volume is about %7 Normal blood volume is about %7 ofof

body weightbody weight

a 70 man # 5 Litrea 70 man # 5 Litre

Clinical manifestation of Clinical manifestation of shockshock

Classification of (H.S.)Classification of (H.S.): :

Dx . Of Hypovolemic shockDx . Of Hypovolemic shock::

Goal isGoal is: :

Restore adequate tissue perfusionRestore adequate tissue perfusion..

resuscitation is similar traumatized patientresuscitation is similar traumatized patient::

- - Stablishing Air wayStablishing Air way

- - Stabilizing cervical spineStabilizing cervical spine

- - Dealing with ventilatory difficultiesDealing with ventilatory difficulties

- - Managing circulatory problemManaging circulatory problem

- - IV line – 16 G.cathaterIV line – 16 G.cathater

Dx of HVSDx of HVS::

11 . .Initial fluid resusitationInitial fluid resusitation: :

11 . .Ringer`s lactate orRinger`s lactate or

22 . .Normal salineNormal saline

DisadvantagesDisadvantages::

Hyperchloremic acidosis especially Hyperchloremic acidosis especially Impared renal function Impared renal function

- - Warming fluid for avoiding HypothermiaWarming fluid for avoiding Hypothermia

11 – – 22 L ImmediatelyL Immediately

Dx of HVS:Dx of HVS: ContCont……

22..CrystaloidsCrystaloids:: Mixture of sodium chloride & other Mixture of sodium chloride & other

Physiologically active solutes Physiologically active solutesمایع- مقدار کننده تعیین کریستالوئید مایع سدیم مایع- میزان مقدار کننده تعیین کریستالوئید مایع سدیم میزان

. بود خواهد .معرفی بود خواهد معرفیدر- عمدتا در- سدیم عمدتا %%8080و و Extra cellular SpaceExtra cellular SpaceسدیمExtra vascularExtra vascular. .است است

در- مایع تجمع سبب ها در- کریستالوئید مایع تجمع سبب ها Interstitial SpaceInterstitial Spaceکریستالوئیددر و شود در می و شود تقریبا Vascular SpaceVascular Spaceمی حدود و تقریبا کمتر حدود و % % 2020کمتر

. باشد .می باشد می

Dx of HVS :Dx of HVS : ContCont……

ها : کریستالوئید ها :عوارض کریستالوئید عوارض Hyperchloremic Metabolic acidosisHyperchloremic Metabolic acidosis

- - Drug interaction due toDrug interaction due to Calcium binding Ringer loctateCalcium binding Ringer loctate

“ “ Balanced Electrolyte solution contain NaBalanced Electrolyte solution contain Na , , Ca,KCa,K“ “

ContraindicationContraindication: : - - Dextrose – containing solutionDextrose – containing solution

( ( ischemia to organischemia to organ) )

Dx of HVS:Dx of HVS: ContCont……

33 . .ColloidsColloids: :

موئینه عروق دیواره از و دارد بزرگ موئینه ملکولهای عروق دیواره از و دارد بزرگ ملکولهای

را مایعات و کند می مثبت اسمزی فشار ایجاد و گذرد را نمی مایعات و کند می مثبت اسمزی فشار ایجاد و گذرد نمی

. از ناشی شوکهای در باالیی مصرف کشاند می عروق . بداخل از ناشی شوکهای در باالیی مصرف کشاند می عروق بداخل

دارد دارد هیپوولمی هیپوولمی

- - Human serum albuminHuman serum albumin

- - Hydroxyl ethyl starchHydroxyl ethyl starch

- - DextransDextrans

Dx of HVS:Dx of HVS: ContCont……

3-13-1 . .AlbuminAlbumin: : - - %80%80 of osmotic plasma pressureof osmotic plasma pressure

- - Carrier protein of Ca , MgCarrier protein of Ca , Mg.. - - AvailableAvailable: :

%5%5 ( ( 5050 g/lg/l ) ) or %25 (250 g/l )or %25 (250 g/l ) in isotonic salinein isotonic saline

- - Increase 5 time intravascular volumeIncrease 5 time intravascular volume - -DisadvDisadv: :

Allergic reactionAllergic reaction - - Half life 36 HsHalf life 36 Hs

Dx of HVS:Dx of HVS: ContCont……

3-23-2 . .HetastarchHetastarch: :

- - Synthetic Starch %6 ( 60 g/l )Synthetic Starch %6 ( 60 g/l )

in isotonic solutionin isotonic solution

- - Half life 24 / HHalf life 24 / H

- -DisadvantageDisadvantage ::

- - Hyper AmylasemiaHyper Amylasemia

- - AllergyAllergy

Dx of HVS:Dx of HVS: ContCont……

3-33-3 . .Dextran – 40Dextran – 40 - - Polysaccharide Sugar beetPolysaccharide Sugar beet

- - Expand intravascular volume twiceExpand intravascular volume twice - - Half life 6 HsHalf life 6 Hs

- -Dis advDis adv: : - - Bleeding risk inhibition of Bleeding risk inhibition of

platelet aggregation platelet aggregation - - AnaphylaxiaAnaphylaxia

- - Interference with crossmatchingInterference with crossmatching - - Acute renal failure Hypoosmolar stateAcute renal failure Hypoosmolar state

Dx of HVS:Dx of HVS: ContCont……

44 - - Hypertonic SalineHypertonic Saline: : %7.5%7.5 NaCl or ( 750 g/l )NaCl or ( 750 g/l )

Infusion RateInfusion Rate: : 44 mL / Kg / 2 minutesmL / Kg / 2 minutes

Maintain pressure 1 - 2 HsMaintain pressure 1 - 2 Hs AmountAmount: :

250250 mL infusionmL infusion Dis advDis adv: :

- - uncontrol Hemorrhageuncontrol Hemorrhage - - Systemic acidosisSystemic acidosis

Dx of HVS:Dx of HVS: ContCont……

55 – – Blood Component therapy ( BCT )Blood Component therapy ( BCT ) - - Fully crossmatched bloodFully crossmatched blood

time 1 hourtime 1 hour Specific or saline crossmatchedSpecific or saline crossmatched

time 10 minutestime 10 minutes - - ABO grouping - RhABO grouping - Rh

- - Whole bloodWhole blood Bag ( 450 ml ) with 50 ml AnticoagulantBag ( 450 ml ) with 50 ml Anticoagulant

preservative (citrate , dextrose , phosphate )preservative (citrate , dextrose , phosphate ) - - Stored 1 – 6 Stored 1 – 6 ̊c̊c

Dx of HVS:Dx of HVS: ContCont……

55 – – Blood component therapyBlood component therapy

- - Shelf life of whole blood 21 daysShelf life of whole blood 21 days

- - Packed cellsPacked cells

- - Blood warmer / pressurizedBlood warmer / pressurized

infusion ( 200 mmHg – 2 to 3 times )infusion ( 200 mmHg – 2 to 3 times )

- - Use wide – bore catheterUse wide – bore catheter

Note Warming blood reduces it Note Warming blood reduces it viscosityviscosity

Dx of HVS:Dx of HVS: ContCont……

66 – – Ultimate goal of DxUltimate goal of Dx: :

- - Normal blood pressureNormal blood pressure

Heart rateHeart rate

Urine outputUrine output

The The EndEnd