Shock

shock, classification, management

1. Presenter: Dr. A. R. Shaan (2 nd yr PGT, Surgery) Moderator: Dr. P P Dhar ( Asst Prof, Surgery) SHOCK…!!

2. SHOCK Failure to meet the metabolic demands of cell and the consequences that ensue

3. Claude Bernard (1813-1878) “ Milieu Interieur ”

4. Walter Bradford Cannon (1871-1945) Homeostasis Flight fight response Toxic factor

5. Alfred Blalock (1899-1964) Proposed 4 categories of Shock (1934) hypovolemic vasogenic neurogenic cardiogenic

6. Classification of Shock Hypovolemic Cardiogenic Septic(Vasodilatory) Neurogenic Traumatic Obstructive

7. Pathophysiology of Shock Decreased tissue perfusion Decreased delivery of metabolic substrate Decreased removal of cellular waste Decreased O 2 delivery/transport/utilization

8. Host- microbe equilibrium T rauma Bacterial Products (LPS) Tissue injury DAMP (HMGB1, Heparan Sulfate) Pattern recognition receptor activation ( Toll like receptors, RAGE) Cellular Activation Decreased Tissue perfusion Cellular hypoxia/ischemia SHOCK Acute heart failure Neurogenic Hemorrhage Mediators of inflammation

9. Hemodynamic responses to different types Type of Shock Cardiac Index SVR Venous Capacitance CVP/PCWP SVO 2 Cellular/ metabolic effects Hypovolemic Effect Septic Cause Cardiogenic Effect Neurogenic Effect

10. Hypovolemic/ Hemorrhagic Shock Most common cause of shock in surgical/trauma patients Peripheral vasoconstriction Cerebral and cardiac Autoregulation

11. Diagnosis of Hypovolemic shock Vital Signs Serum Lactate Base deficit Radiological investigations

12. Classification of base defecits Mild (-3to -5mmol/L) Moderate (-6to-9mmol/L) Severe( More than -10mmol/L)

13. Radiological Investigations USG W/A Diagonostic peritoneal tapping Chest Xray PA view Xray long bones CT scan head/ chest/ abdomen

14. Treatment Secure the airway Control source of hemorrhage Volume resuscitation

15. Damage control resuscitation ED OT ICU SBP 80-90 mmHg Blood products, crystalloids Control heamorrhage Prevent hypothermia Prevent coagulopathy

16. Recent concepts in resuscitation Hypotensive resuscitation Delayed fluid resuscitation vs standard fluid resuscitation Early surgery to control heamorrhage

17. Hemostatic resuscitation 1 unit PRBC: 1 unit Plasma: 1 unit Platelet Hb : 7-9g/dl Platelet count : 50,000/L Massive transfusion : >10 units in 24 hrs

18. Coagulation factor based concentrates Fibrinogen concentrates ; prothrombin complex cocentrates Tranexemic acid: Antifibrinolytic agents Thromboelastography (TEG)

19. Traumatic Shock Soft tissue injury + Bone fractures+ Blood Loss Hypoperfusion + proinflammatory activation DAMP

20. Septic (Vasodilatory) Shock Systemic response to infection Non infectious causes Anaphylaxis Acute adrenal insufficiency Prolonged severe hypotension Metabolic

21. Surviving sepsis campaign bundles To be completed in first 3 hrs lactate level blood cultures Broad spectrum antibiotics Crystalloid 30ml/kg

22. Surviving sepsis campaign bundles To be completed within 6 hrs Vasopressors MAP≥65 mmHg CVP and SVO 2 monitoring Remeasure lactate CVP > 8 mmHg; SVO 2 > 70%; normalization of lacate

23. Cardiogenic Shock Acute myocardial infarction Arrhythmia End stage cardiomyopathy Myocarditis Severe myocardial contusion Left ventricular outflow obstruction Acute mitral regurgitation

24. Treatment Airway and ventilation Oxygenation Correction of hypovolemia Pain management Ionotropes Mechanical Circulatory support

25. Obstructive Shock Pericardial Tamponade Pulmonary embolus Tension pneumothorax IVC Obstruction Increased intrathoraxic pressure

26. Neurogenic Shock Spinal Cord trauma Spinal Cord Neoplasm Spinal/Epidural anesthesia

27. Endpoints in resuscitation Systemic/ Global Lactate Base deficit Cardiac output Oxygen delivery & Consumption Tissue specific Gastric tonometry Tissue pH, O 2 , CO 2 levels Near infrared spectroscopy Cellular Membrane Potential Adenosine triphosphate

28. “Shock from severe wounds and haemorrhage always must take precedence of everything else.” William W Keen Thank You……..