Hypovolemic shock

CME on hypovolemic shock.

1. Hypovolemic Shock Ivan De Paz MD WRH

2. SHOCK Hippócrates 400 BC 1740 choc por Henry francois 1743 Clarke shock Sudden worsening of patient’s clinical status after trauma Collins - Temporary pause in the process of dying HIPPOCRATES

3. SHOCK 1861 Samuel Gross Alternative etiologies besides hemorrhage

4. FACTS Shock is a life-threatening condition of circulatory failure. The effects of shock are initially reversible, but rapidly become irreversible, resulting in multiorgan failure (MOF) and death

5. DEFINITION A state of cellular and tissue hypoxia due to reduced oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization

6. CLASSIFICATION

7. CHARACTERISTICS OF SHOCK Hypotension Altered mental status Oliguria Tachypnea Cool clammy skin Delayed capillary refill Metabolic acidosis

8. HIPOVOLEMIC SHOCK

9. Hypovolemic shock Decrease in venous return due to a loss of circulating volume ( internal or external ) Early recognition of the condition is vital, if subsequent tissue injuries are to be avoided

10. Hypovolemic Shock Hemorrhágic VS non hemorrhágic Generally , is the first differential in the hypoperfused patient Blood volume adult 66 ml/kg ♂ y 60 ♀ Patient that lost 30-40% of total blood volume can develop cardiac arrest In Non Trauma patients , most of the hemorrhages are located in the abdomen

11. Non Hemorrhagic Gastroenteritis Burns Fistulas Excessive Diuresis

12. Hemorrhagic TRAUMATIC Vs NON TRAUMATIC Solid Organ Injury Lung Parenchyma Injury Myocardial injury Vascular Injury Retroperitoneal Bleeding Duodenal Ulcer Renal injury Long bone fracture/ pelvic fracture Scal p lacerations Epistaxis

13. Hemorrhagic Gastrointestinal Esophageal varices Peptic ulcer Mallory Weiss Syndrome Gastric CA/ colon Vascular Lesions (AV Malformations ) Ulcerative colitis Ischemic colitis

14. Hemorrhagic REPRODUCTIVE ORGANS Vaginal Bleeding cancer Miscarriage Fibroids Retained placentae placenta previa Ectopic pregnancy Ruptured ovarian cyst

15. Hemorrhagic Vascular Aneurysm Aorto =enteric fistula AV malformations

16. Categories of acute blood loss Critical care medicine. principles of diagnosis and management in the adult

17. Class II Hemorrhage Compensatory mechanisms begin to fail Tachycardia Tachypnea Decreased pulse pressure Delayed capillary refill SBP changes minimally if at all Skin may be cool and clammy

18. Class III Hemorrhage Significant Drop in blood pressure Changes in mental status Heart rate >120x’ Tachypnea Urine output decreased Capillary refill delayed

19. Class IV Hemorrhage Marked hypotension Abnormal mental status Heart rate >120x’ Narrow pulse pressure Urine output minimal Capillary refill delayed Skin is cold and pale

20. Management

21. Goals of treatment

22. Lactate levels Measure lactate levels in all cases were shock is suspected Levels typically > 2 mEq /L in shock states Can be performed every 2 hours (1st 8 hrs) & then every 8-12 hrs

23. Challenges Docs no longer touch patients, they order tests A good history and detailed PE are needed A high index of suspicion Identify your patient’s basal status and work towards specific goals

24. Learn from the mountain goat

25. Mumtaz mahal

26. Thank you