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ShockShock
Year 4 TutorialsYear 4 Tutorials
A B A B C C D ED E
Objectives:Objectives:
What is shock?What is shock?
Types of shockTypes of shock
Management principlesManagement principles
Shock Definition:Shock Definition:
State of inadequate tissue perfusion and tissue State of inadequate tissue perfusion and tissue oxygenation as a result of a deficiency in the oxygenation as a result of a deficiency in the
circulationcirculation
Types of Shock:Types of Shock:
Distributive – SepticDistributive – Septic
AnaphylacticAnaphylactic
NeurogenicNeurogenic CardiogenicCardiogenic Obstructive –Obstructive – Tension pneumothorax Tension pneumothorax
Cardiac tamponadeCardiac tamponade HypovolaemicHypovolaemic
BP = CO x SVRBP = CO x SVR
HR x SVHR x SVNormal vascular tone
determined by sympathetic innervation
•Contractility•Preload (ventricle stretch)•Afterload
CARDIAC PHYSIOLOGY
Distributive - SepsisDistributive - Sepsis
SIRS = 2 of SIRS = 2 of RR > 20 breaths per minute RR > 20 breaths per minute WCC < 4 or > 12 WCC < 4 or > 12 Heart rate > 90 beats per minute Heart rate > 90 beats per minute Temperature: Fever > 38.0 °C or < 36.0 °CTemperature: Fever > 38.0 °C or < 36.0 °C
Sepsis = SIRS + Evidence of infectionSepsis = SIRS + Evidence of infection
Distributive - SepticDistributive - Septic
Massive vasodilationMassive vasodilation BP = CO x BP = CO x SVR ( )SVR ( )
Often dehydratedOften dehydrated
Fluids & antibiotics, Fluids & antibiotics,
Vasoconstrictors.Vasoconstrictors.
Distributive - AnaphylaxisDistributive - Anaphylaxis
Massive vasodilationMassive vasodilation
Type 1 hypersensitivityType 1 hypersensitivity
Treatment:Treatment: Fluids, adrenaline, Fluids, adrenaline,
chlorphenamine, steroidschlorphenamine, steroids ?Anaesthetist?Anaesthetist
Distributive - Neurogenic Distributive - Neurogenic
Massive vasodilationMassive vasodilation
Loss of sympathetic Loss of sympathetic vascular tone.vascular tone.
Fluids and Fluids and vasoconstrictors.vasoconstrictors.
Cardiogenic shockCardiogenic shock
PUMP failure!PUMP failure! Cannot empty pumpCannot empty pump
BP = BP = CO CO x SVRx SVR
CO = CO = HRHR x x SVSV ( contractility)( contractility)
Causes:Causes: Acute MIAcute MI
Large InfarctionLarge Infarction Papillary muscle rupturePapillary muscle rupture
Other ConditionsOther Conditions Septic shockSeptic shock MyocarditisMyocarditis Arrhythmias Arrhythmias Drugs – eg beta-blocker Drugs – eg beta-blocker
overdoseoverdose Myocardial contusionMyocardial contusion
Cardiogenic shockCardiogenic shock
Treat underlying Treat underlying cause if possiblecause if possible
Inotropes.Inotropes. Balloon pumpBalloon pump
Obstructive –Tension PneumothoraxObstructive –Tension Pneumothorax
Accumulation of air Accumulation of air under pressure in the under pressure in the pleural space. pleural space.
1-way valve1-way valve
Mediastinal shift: Mediastinal shift: preload & afterload = preload & afterload = SV SV
Obstructive –Tension PneumothoraxObstructive –Tension Pneumothorax
Treatment:Treatment: Needle decompressionNeedle decompression Chest drainChest drain
Obstructive – Cardiac Tamponade Obstructive – Cardiac Tamponade
Accumulation of fluid in Accumulation of fluid in the pericardial space, the pericardial space, resulting in reduced resulting in reduced ventricular fillingventricular filling
Rapid filling of only 150ml Rapid filling of only 150ml causes compromisecauses compromise
Obstructive – Cardiac Tamponade Obstructive – Cardiac Tamponade
Becks triad:Becks triad: increased jugular venous increased jugular venous
pressure, pressure, hypotension hypotension diminished heart sounds.diminished heart sounds.
Treatment: needle Treatment: needle pericardiocentesispericardiocentesis
Hypovolaemic ShockHypovolaemic Shock
The system is DRY.The system is DRY. Causes:Causes:
HaemorrhageHaemorrhage SepsisSepsis D&VD&V
BP = BP = COCO x SVR x SVR CO = HR x CO = HR x SVSV
Hypovolaemic / HaemorrhagicHypovolaemic / Haemorrhagic
Where is the Blood?Where is the Blood?
RevealedRevealed On the floor, at the sceneOn the floor, at the scene
ConcealedConcealed ChestChest Peritoneal/PelvisPeritoneal/Pelvis Long bonesLong bones RetroperitoneumRetroperitoneum
Hypvolaemic shock management:Hypvolaemic shock management:
Treat underlying cause Treat underlying cause haemorrhage control – 1haemorrhage control – 1stst aid, angio, theatre aid, angio, theatre
Venous access / fluidsVenous access / fluids
Fluid replacementFluid replacement
Vascular access:Vascular access:
TWO TWO large venflonslarge venflons
Where? Where? Anticubital fossaAnticubital fossa
Consider IOConsider IO Take samples – X-matchTake samples – X-match
Initial fluid therapy:Initial fluid therapy:
CrystalloidCrystalloid
ColloidColloid
Consider warmingConsider warming
Cross matchedCross matched
Type specificType specific
‘‘O’ negativeO’ negative
Massive transfusion Massive transfusion protocolprotocol
Response to fluid treatment:Response to fluid treatment:
General General
Urine - 30ml / hour (0.5mg/kg)Urine - 30ml / hour (0.5mg/kg)
Acid / Base balance (lactic acidosis)Acid / Base balance (lactic acidosis)
Shock summaryShock summary
Distributive – Distributive – vasodilation - reduced vasodilation - reduced
SVRSVR
Cardiogenic – Cardiogenic – reduced heart rate / reduced heart rate /
stroke volume - pump stroke volume - pump failurefailure
Obstructive – Obstructive – reduced stroke reduced stroke
volume – blood canvolume – blood can’’t t get in or outget in or out
Hypovolaemic –Hypovolaemic – reduced stroke reduced stroke
volume - lack of blood volume - lack of blood volumevolume
May be a combination
Shock summaryShock summary
ABCsABCs Assess degree and causeAssess degree and cause Intervene: Intervene:
Treat underlying causeTreat underlying cause Maintain CO and SVR - fluids, vasocostictors, Maintain CO and SVR - fluids, vasocostictors,
inotropesinotropes ReassessReassess Get HELPGet HELP
QuestionsQuestions
??A&E Department, Aberdeen Royal Infirmary
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