SHOCKDela Cruz, Czarino Diaz, Mark AnthonyDela Cruz, Fatima Diaz, Mark Fernan Dela Cruz, Isabella Dimaunahan, Eric
A 47-year old male is admitted to the ER because of blunt injury to the left side of the chest and abdomen sustained in a vehicular accident 30 min prior. He is conscious, incoherent, disoriented, and agitated. Pallor and cold clammy extremities are noted. BP: 70, palpatory, pulses are faint and thready, RR: 12/mm. A violaceous contusion hematoma is noted over the 5th to 8th ICS, extending from the L midaxillary line to the L midclavicular line. The abdomen is flabby soft and distended; patient gets agitated whenever palpation is attempted.
1. WHAT ARE THE SIGNS OF SHOCK PRESENT IN THE PATIENT?
1. What are the signs of shock present in the patient?
Recognition of Shock• Blood pressure• pulse rate• Pallor• Temperature• Mentation• Urine output• Central Venous Pressure / PCWP
1. What are the signs of shock present in the patient?
Recognition of Shock
• Blood pressure (70, diastole)
• pulse rate (faint and thready)
• Pallor ( + )
• Temperature (cold)
• Mentation (conscious, incoherent, disoriented, and agitated)
a. What type of shock is present?
TRAUMATIC SHOCK
• Hypovolemic Shock
• direct soft tissue injury (violaceous contusion hematoma is noted over the 5th to 8th ICS, extending from the L midaxillary line to the L midclavicular line)
b. What degree (class) of shock will manifest these signs?
Class III 3--40 % BV
• classical clinical manifestations
c. Explain the etiology of each of the signs noted.
Hypovolemic ShockCauses: intravascular volume depletion -hemorrhage plasma volume -
extravascular sequestration GI,GU, insensible losses Hypoperfusion
↓ blood volume ↓cardiac output ↑ peripheral vasoconstriction (compensatory)
c. Explain the etiology of each of the signs noted.
Low Blood pressure ( BV and CO)
• faint and thready pulse rate ( BV and CO)
• Pallor skin ( peripheral vasoconstriction)
• Low Temperature ( BV and CO, peripheral vasoconstriction)
• conscious, incoherent, disoriented, and agitated ( BV and CO)
d. Explain how the initial neurohormonal responses to injury allow this patient to survive.
Corticotrophin Releasing Hormone
ACTH Cortisol
Injury
Anterior Pituitary
HYPOTHALAMUS
LIVER:
Promotes enzymatic activities Leading to gluconeogenesis
PERIPHERAL:
Induces proteolysis and lactate release in skeletal muscle.
Induces lipolysis . Inhibit glucose uptake by adipose tissue .
HYPERGLYCEMIA
CORTISOL
Growth Hormone Releasing Hormone
Injury
Anterior Pituitary
HYPOTHALAMUS
Growth hormone
Promotes protein synthesis.
Enhances mobilization of fat stores.
Plasma Osmolal
ity
Reabsorption of water in the renal distal tubules andCollecting ducts. Splanchnic vasoconstriction
Enhances glycogenolysis and gluconeogenesis.
Effective Circulatory Volume
POSTERIOR
PITUITARY
VP
Juxtaglomerularapparatus
Decreased blood flow
Renin
Angiotensinogen Angiotensin I
ACE
Aldosterone
Restoration of blood volume
Angiotensin II
2. WHAT ARE THE TWO BASIC PRINCIPLES IN THE MANAGEMENT OF HYPOVOLEMIC SHOCK?
1. Replace lost volume.
2. Stop bleeding.
a. How will you apply these principles to this patient?
Maximizing oxygen delivery The patient's airway should be assessed
immediately upon arrival and stabilized if necessary. The depth and rate of respirations, as well as breath
sounds, should be assessed. If pathology (eg, pneumothorax, hemothorax, flail chest) that interferes with breathing is found, it should be addressed immediately.
High-flow supplemental oxygen should be administered to all patients, and ventilatory support should be given, if needed
Placement of an arterial line should be considered for patients with severe hemorrhage- provide continuous blood pressure monitoring and also ease arterial blood gas testing.
Once IV access is obtained, initial fluid resuscitation is performed with an isotonic crystalloid, such as lactated Ringer solution or normal saline.
Controlling further blood loss Control of further hemorrhage depends on the
source of bleeding and often requires surgical intervention.
In the patient with trauma, external bleeding should be controlled with direct pressure; internal bleeding requires surgical intervention
In the patient with GI bleeding, intravenous vasopressin and H2 blockers have been used.
b. What are the appropriate IV fluids to administer?
Conventional crystalloids Balanced salt solutions (BSS) and hypotonic salt
solutions Balanced salt solutions include such fluids as 0.9%
NaCl (normal saline), and Ringer's Lactate solutions.
Have an electrolyte composition or calculated osmolality approximating that of plasma (isotonic)
Distribute approximately ¾ of their volume to the extravascular space with ¼ of the volume remaining in the intravascular space.
Colloid solutions Solutions of proteins, starches, dextrans, and gelatins
containing molecules sufficiently large enough so that they do not normally cross capillary membranes.
Most of the administered volume remains in the intravascular space (unless tissue is damaged and then it can cross membranes).
Once colloids have leaked into the interstitium, they must be removed by the lymphatic system or they will exert a reverse pressure gradient, drawing water from the vascular space.
Guidelines for replacement
the amount of fluid to be given the time period over which the fluid is given the type of tubing and drop size
An initial bolus of 1-2 L is given in an adult (20 mL/kg in a pediatric patient), and the patient's response is assessed.
2-3 L over 20 to 30 mins should restore normal hemodynamic parameters
Continued hemodynamic instability- shock not reversed; ongoing blood or volume losses
Continuing blood loss (hemogloblin concentrations declining to <10g/dL)- initiate blood transfusion
Severe and/or prolonged hypovolemia- inotropic support with dopamine, vasopressin or dobutamine
Discuss the limitations of volume/volume replacement with crystalloids to correct the shock state.
Crystalloids - aqueous solutions of mineral salts or other water-
soluble molecules.
- used in IV transfusion
Solution Other Name [Na+](mmol/L)
[Cl-](mmol/L)
[Glucose](mmol/L)
[Glucose](mg/dl)
D5W 5% Dextrose 0 0 278 5000
2/3D & 1/3S 3.3% Dextrose / 0.3% saline
51 51 185 3333
Half-normal saline 0.45% NaCl 77 77 0 0
Normal saline 0.9% NaCl 154 154 0 0
Ringer's lactate Lactated Ringer 130 109 0 0
Composition of Common Crystalloid Solutions
After infusion of 1L of IV fluid
Solution Change in ECF Change in ICF
D5W 333 mL 667 mL
2/3D & 1/3S 556 mL 444 mL
Half-normal saline 667 mL 333 mL
Normal saline 1000 mL 0 mL
Ringer's lactate 900 mL 100 mL
TIP: Don’t start I.V. lines in the legs of a patient in shock who has suffered abdominal trauma because infused fluid may escape through the ruptured vessel into the abdomen.
Advantages - safe and inexpensive - equilibrates rapidly throughout the extracellular compartment, restoring the
ECF deficit
Disadvantages - because of the rapid equilibration of balanced salt solutions into the EC space, larger volumes may be required for adequate
resuscitationresulting in decreased intravascular oncotic pressure
c. Where is the most probable site of bleeding?
c. Where is the most probable site of bleeding?
LH region organs
Stomach
Spleen
Tail of Pancreas
Splenic flexure of the colon
Hilus of left kidney
Left adrenal gland
c. Where is the most probable site of bleeding?
Hematoma at 5th ICS to 8th ICS extending from L midaxillary to L midclavicular
As the blunt injury suggests, affected vessels may be the intercostal arteries resulting to hematome, otherwise if deeper vessels like splenic or superior mesenteric arteries, blood will accumulate on abdominal spaces
How do you stop the bleeding using the second principle?
Management of Shock
1. Blood and fluid replacement
2. Stop further bleeding
How do you stop the bleeding using the second principle? While initial stabilization is taking place,
attention should be directed to prompt arrest of bleeding
Aggressive restoration of normal BP without arrest of internal hemorrhage will enhance further losses of blood volume by increasing flow and impeding coagulation at the site of injury.
How do you stop the bleeding using the second principle? Mild to moderate hypotension allows for clot
formation and slows bleeding from injured blood vessels (hypotensive resuscitation).
The hemodynamically unstable injured victim should be brought to surgery as soon as possible and the source of bleeding should be promptly identified and arrested.
3. WHAT ARE THE CONSEQUENCES OF THE SHOCK STATE ON THE INDIVIDUAL ORGAN SYSTEMS,I.E., KIDNEYS, LUNGS?a. Discuss the etiopathogenesis of ARDS and ATN.
Shock
serious, life-threatening condition where insufficient blood flow reaches the body
hypoperfusion
Stages of Shock
Initial Compensatory Progressive Refractory
Initial stage
Hypoxia Unable to produce ATP Cell membrane become damaged and leaky
to extracellular fluid Metabolic acidosis
Compensatory stage
Hyperventilation Production of adrenaline and noradrenaline Vasoconstriction and increase heart rate Increase BP Renin-angiotensin system activation to
conserve fluid Diversion of blood flow to the heart, lungs and
brain
Progressive stage
Arteriolar and precapillary sphincters constrict Blood remains in the capillaries Increase hydrostatic pressure will lead to
leakage of fluid and protein in the surrounding tissue
Blood viscosity increases
Refractory stage
Irreversible Death
ARDS (Acute Respiratory Distress Syndrome)
breathing failure that occurs when there is severe fluid buildup in the lungs
tiny blood vessels or the air sacs are damaged Fluid leaks from the blood vessels into air sacs lungs can no longer fill properly with air and
the lungs become stiff
Causes of ARDS
Direct from breathing in
harmful substances or an infection in the lungs
Example: Breathing in vomited
stomach contents A severe blow to the
chest or other accident that bruises the lungs
Indirect happen in people
who are very ill or who have been in a major accident.
Example: Severe and
widespread bacterial infection in the body
Severe injury with shock
ATN (Acute Tubular Necrosis)
a kidney disorder involving damage to the tubule cells of the kidneys
Lead to kidney failure caused by lack of
oxygen to the kidney tissues (ischemia of the kidneys), or by exposure to materials that are poisonous to the kidney
4. WHAT IS THE PRINCIPLE OF PASG (PNEUMATIC ANTI-SHOCK GARMENT)?
PASG
medical device which may increase peripheral resistance
reduce the effort with which the heart must pump blood to perfuse the vital organs
reduce the available area into which a patient may hemorrhage
effectively increase the blood pressure
Indications for use
patient's systolic blood pressure falls below 60 mmHg
patient presents with signs and symptoms of shock
Unstable pelvis fracture with suspected intra-pelvic hemorrhage
Unilateral or bilateral femur fracture
Contraindications
Pulmonary edema Cardiogenic shock Penetrating intrathoracic trauma Major blunt intrathoracic trauma Patients with chronic obstructive pulmonary
disease Patients with possible cerebral edema Patients suspected of having a CVA Pregnancy Abdominal evisceration
CASE II
A 13 year old boy is admitted because of continuous R lower quadrant pain of 1 week duration accompanied by fever (of 5 days duration), vomiting, and diarrhea (of 3 days duration). On admission, he is lethargic and disoriented. BP: 90/70 PR: 110/min RR: 26/min T: 39 C. The patient’s abdomen is positive for direct and rebound tenderness over all quadrants.
Points for discussion:1. What signs of shock are present in this patient?2. What procedures/ lab requests would give you a better evaluation of the patient’s fluid status?3. Discuss the pathophysiology of this type of shock.a. Correlate the pathophysiology with the management recommended.b. Discuss the role of vasopressors in treatment.
Signs of Shock
Blood pressure: BP: 90/70
Pulse Rate: PR: 110/min
Respiratory Rate : RR: 26/min
Mentation: lethargic and disoriented
Temperature: T: 39 C fever (of 5 days duration)
Vomiting, and diarrhea (of 3 days duration)
Evaluation of Patient’s Fluid Status
Procedures To Get A Better Evaluation Of The Patients Fluid Status
Medical History and Physical Examination
Physiological Signs and Symptoms (eg. fever, vomitting and tachypnea)
Functional Signs and Symptoms (eg. lethargy and weakness)
Laboratory Tests That May Help to Characterize the Nature and Severity of Fluid/Electrolyte Imbalance
Highly recommended: sodium, potassium, chloride, bicarbonate (electrolytes), blood urea nitrogen (BUN), creatinine
Recommended: calcium, glucose, hemoglobin, hematocrit, serum osmolality
Optional: urinalysis, urine sodium, urine osmolality
Discuss the pathophysiology of this type of shock
1) Correlate the pathophysiology with the management recommended.
2) Discuss the role of vasopressin in treatment.
Septic Shock
By-product of the body’s response to invasive localized infection
Bacterial and fungal pathogens Diagnosis:
Evidence of infection (positive blood culture) Refractory hypotension (despite fluid
resuscitation and cardiac output) Additional criteria
Hyperventilation (> 20 breaths / min) WBC count (<4000 cells/mm or >12000
cells/mm)
Pathophysiology
Pain
Fever
Vomiting
Diarrhea
Positive for direct and rebound tenderness
in the abdomen
Clinical symptoms
Management
Antibiotics (Cefuroxime and Metronidazole)
Surgery (Appendectomy)
IV and electrolyte fluids
Infusion of Protein C Vasopressors
Vasopressors
Used for hypotensive patients besides fluid resuscitation
Vasoconstriction Increase arterial
pressure Reabsorption of
water in the renal tubules and collecting ducts
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