shock and Hemorrhage. ppt [ janvi ]

Hey, Janvi Mishra this side. Presentation topic is Shock and Hemorrhage which was presented by me during my general surgery days. You can take help from this slide. Hope you will like it.

1. SHOCK AND HEMORRHAGE Janvi Mishra

2. Hemorrhage Hemorrhage is a acute loss of blood from a damaged blood vessel. The bleeding can be minor, such as when the superficial vessel in the skin are damaged, bleeding & ecchymosis. As the blood carries oxygen & nutrients to the tissues & is vital for body function. Loss of blood due to any reason beyond a certain point is life threatening & may lead to exsanguination ( blood loss to a sufficient degree to cause death) If a hemorrhage is severe it may lead to patient in a shock.

3. Classification Hemorrhage following oral surgical procedures can occur due to local / systemic procedures. Many times, we encounter postoperative bleeding in healthy patients due to local causes. This type of blood loss originate in soft tissues of bone. Classification l ( Depending on the type of blood vessel involved ) Arterial Hemorrhage- bleeding from ruptured artery Bright red in colour, sprout like jet along with rhythm of pulse of the patient Emitted as a jet with heartbeat Escapes from both end of vessel

4. 2) Venous hemorrhage – loss of blood from vein Blood flow is dark, steady & continuous No sprouting, rate of loss is severe Due to lack of valves in veins of the facial region & extensive communication there is realtively more flow from these veins as compared to other parts. 3) Capillary hemorrhage – Oozing from the capillaries is known as capillary Hemorrhage Bleeding is bright red/ darkish in colour. In capillary Hemorrhage, blood oozes from the area & no bleeding point can be made out Bleeding is not severe & is easily controlled by simple pressure with gauze pads

5. Classification ll ( depending upon the time of Hemorrhage ) 1) Primary bleeding – Occurs at the time of injury / operation Intermediate Hemorrhage Hemostatic mechanism in the body attempt to stop bleeding by formation of a clot. 2) Reactionary/ intermediate bleeding- Bleeding occurring within 8hrs after the stoppage of primary bleeding. It may occur after the 24hrs of surgery or 4-6hrs after the injury. E.g.

6. Thyroid surgery Circumcision surgery

7. 3) Secondary bleeding- If the primary bleeding has stopped once & wound starts to bleed after 24hrs to several days, it is known as secondary bleeding. Occuring 7-14 days after surgery It may be due to a) Dislodgment of clot b) secondary trauma to a wound c) infection ( most common reason) d) elevation in patients blood pressure E.g.

8. Erosion of carotid artery Inguinal block dissection Hemorrhoidectomy

9. Classification lll Revealed Hemorrhage – visible external Hemorrhage Concealed Hemorrhage – constitutes internal Hemorrhage, liver injury, spleen injury. Intially concealed Hemorrhage - hematemesis, melena, femur fracture, cerebral Hemorrhage, hemothorax Classification lV 1) Acute Hemorrhage- Sudden, severe Hemorrhage after trauma, surgery Produces a decrease in arterial systolic, diastolic & pulse pressures along with an increase in the pulse rate & a decrease in the cardic stroke volume.

10. 2) Chronic Hemorrhage- chronic repeated bleeding for long time like hemorrhoids, bleeding peptic ulcer, carcinoma cecum etc. Present with chronic anemia & are in the state of chronic hypoxia which is corrected by packed cell transfusion not by whole blood itself 3) Acute / chronic Hemorrhage- More dangerous as the bleeding occurs in individuals who are already hypoxic, the situation get worst rapidly.

11. Clinical features Pallor, cynosis Trachycardia, tachypnea Cold, clammy skin due to vasoconstriction Dry face, dry mouth & goose skin appearance Rapid pulse, hypotension, oliguria Signs of blood loss significantly Pulse >100bpm Systolic bp < 100mm hg Pallor/sweating Shock index > 1

12. Pathophysiology

13. Treatment Some of the common treatment for this is- Pressure & dressing – Apply frim, steady pressure to the wound. Using a clean cloth or a gauze for at least 5mins & dressing it properly Staples or stiches- stiches closes the wound & stop the bleeding Cauterization- Applying heat or chemicals to burn & seal the wound. This may require cauterization tool or silver nitrate sticks.

14. Surgery- In severe cases surgery may be necessary to repair damaged blood vessel or organs Hemostatic agents- Tranexamic acid (TXA)- Adult dose [ 1-2 gms, IV & 3 to 4 times a day ] ; Aminocapricoic acid- Adult dose [ 4-5 gms,IV 3 to 4 times a day Other – Oxytocin (pitocin) 10-40 units IM or IV Misoprostol ( Cytotec) 800-1000mcg orally

15. SHOCK

16. Causes of circulation failure

17. Types of shock On the basis of pathophysiology and hemodynamic changes shock can be classified into – Cardiogenic shock Septic shock Hypovolemic shock Anaphylactic shock Neurogenic shock

18. Cardiogenic shock This shock occurs as a result of inadequate cardic output, impaired oxygen delivery and reduced tissue perfusion caused by loss of effective contractile function of myocardium from mechanical processes. Results due to intrinsic problem within the cardic muscle or valve causing decreased cardic function. Cardic surgical causes – valvular disease, congenital heart disease .

19. Signs and symptoms – Distended juglar vein due to increased venous pressure Absence pulse due to tachycardia Chest pain Oliguria ( urine output less than 30ml/hr )

20. Initial treatment is directed to identify the cause and maintaining the adequate systemic blood pressure, cardic output and tissue perfusion with volume expansion and inotrophic drugs. Dopamine is the vasopressor of 1 st choice. It is directed in the normal saline of 5% dextrose drip and given at 5-10 microgram/kg/min.

21. Other drugs- vasopressors – ( maintain mean arterial pressure) Doubtamime ( the lower dose can be prescribed is 2.5-5.0 mcg/kg/min & higher can be 5.0-20.0 mcg/kg/min in iv form) Vasodilators (relaxes Smooth vascular muscles, reduce systemic vascular resistance & cardic output

22. nitroglycerines (1.5-3.0mg/h in IV form), Sodium nitoprusside ( diluted with D5W if not suitable for direct injection, range start with 0.5- 4.0 mcg/kg/min, max. Can be 10mcg/kg/min for 20 min only & after that alternative can be used (e.g. celevipidine )

23. Septic shock Septic shock describes the clinical syndrome corresponding to acute circulatory failure resulting from serious infection. Mostly it is proved by gram –ve bacteria, but fungi, virus and parasites can cause inflammatory response causing vasodilation and hypovolemia which leads to septic shock. .

24. 3stages of sepsis- 1) Sepsis is when the infection reaches the bloodstream and causes inflammation in the body. 2) Sepsis is when the infection is severe enough to affect the function of organs e.g.- heart, brain, kidney 3) Septic shock is when there is experience of a significant drop in blood stream pressure that can lead to respiratory or heart failure, stroke, failure of other organs and death.

25. Sign and symptoms- hypotension
Increased heart rate
Hot, dry flushed skin Rapid bounding pulse Wide pulse pressure DIC ( disseminated intravascular coagulation)

26. Causes – E. Coli is the common most bacteria which is gram –ve , facultative, rod-shaped in nature. E.coli sepsis (from indwelling urinary catheter) Urinary retention (secondary to prostate hyperplasia) Spread of localized infection to blood stream (e.g. abscess, pneumonia)

27. Types – 1) early ( warm ) - decreased peripheral vascular retention increased cardic output 2) late ( cold ) – Increased peripheral vascular retention Decreased cardic output

28. Treatment- Norepinephrine – 1 st line septic shock refractory to volume replacements Empiric therapy but should not be continued more than 3-5 days 3 rd generation cephalosporin (Ceftriaxone 50-100 mg/kg Upto 2mg daily + Metronidazole 500mg , 8 hourly )

29. Steroids ( Hydrocortisone 2-6 daily for 2 days – it has anti-inflammatory & anti-shock effects) Monitor urine output ( best indicator) 0.5 – 1ml/kg/hr

30. Anaphylactic shock It is defined as the hypersensitivity reaction to the ingestion of a substance injection resulting from prior contact with a substance. Serious allergic reaction that may cause a death. It is due to type l hypersensitivity reaction.

31. Signs & symptoms Throat edema Hypotension Weak and rapid pulse Skin eruption and large welts Localized edema specially around face Breathless and cough due to narrowing of airways and swelling of throat.

32. Causes Anaphylaxis is caused by a severe allergic reaction. It happens when the immune system mistakes a food or substance for something that’s harmful. In response, the immune system releases a flood of chemicals to fight against it

33. These chemicals are what cause the symptoms of the immune system produces antibodies that defend against foreign substances. This is good when a foreign substance is harmful, such as certain bacteria or viruses. But some people’s immune systems overreact to substances that don’t cause an allergic reaction. Treatment Epinephrine IM 0.3mg 1:1000 ( can be given in anterolateral thigh as it absorbs 7 times faster than the equivalent injection to a deltoid muscle.

34. Neurogenic shock It is a type of shock that is caused by sudden loss of signals from the sympathetic nervous system that maintain the normal muscle tone in blood vessel walls. The blood vessel relax and become dilated resulting in pooling of blood in the venous system and overall decrease in blood pressure. Neurogenic shock can be the complications of injury to the brain / spinal cord.

35. Causes Injury of spinal cord, dental extraction without ineffective anesthesia. “ Vasovagal syncope” or “emotional fainting” most commonly seen in dental clinics is caused by excitation of the parasympathetic nerves to the heart and vasodilator nerve to the skeletal muscle thereby slowing the heart and reducing the arterial pressure. There is decrease in central blood flow below a critical level and the patient usually falls. Consciousness almost return immediately & within short period of time recovery occurs”

36. Signs and symptoms Slowed heart rate Skin is warm and dry Hypotension Treatment Iv- Methylprednisolone – in the arms vein ( treat acute spinal cord injury) less than 3hr after injury (5.4mg/kg/hr for 23hrs) B/w 3-8 hr after injury (5.4mg/kg/hr for 47hrs)

37. Hypovolemic shock Hypovolemic shock can be defined as a decreased in the intravascular blood volume to such an extent that effective tissue perfusion cannot be maintained. Hypovolemic shock is a life threatening emergency in which severe blood or other fluids loss makes the heart unable to pump enough blood to the body. This causes many organs stop working.

38. The normal blood volume in human body – 5L or 7-8% of bw As, it is due to reduction in total blood volume but this can be due to A) Hemorrhage – external wounds, open fractures, Internal form injury to spleen, B ) Severe burns due to loss of plasma C ) Peritonitis, intestinal obstruction D ) Vomiting, diarrhea due to any cause

39. This can be further classified into- 1) Non- Hemorrhagic shock- massive fluid shift from intravascular to extravascular compartment. Results from burns, injury, diarrhea, vomiting, dehydration

40. 2) Hemorrhagic shock- loss of blood from the body as a result of injury. Hemorrhage decrease the mean systemic filling pressure & a resultant decrease of venous return, there is a fall in cardic output.

41. Further classified into- external Hemorrhage- trauma, hematoma Internal Hemorrhage- GI bleeding hemothorax/ hemoperitoneum

42. Pathophysiology of hypovolemic shock

43. Stages of hypovolemic shock

44. Signs and symptoms- Change in heart rate Rising pulse rate ( trachycardia ) Rising respiratory rate ( tachypnea ) Shallow, irregular respirations Failing blood pressure ( hypotension) Decreased or absent urinary output (less than 30ml) Pale skin / pale mucous Cold & calm skin Faintness, thirst

45. Treatment First, of all how to manage hypovolemic shock- Maximize oxygen delivery, control fluid loss, fluid resuscitations.

46. Start 2 IV lines with a large gauze needles (16-18) in both hands. Warned isotonic Crystalloid solution are used for initial resuscitation.
The usual initial dose is 2L in 10-15 min for an adult.

47. Blood test – complete blood cell count (CBC)- how much blood a person has lost. Arterial blood gases (ABG)- helps to confirm hypovolemic shock & it’s severity. HCT- measures the % of red blood cells in the blood. Heart test like electrocardiography ( ECG)

48. In emergency cases, Rapidly, establish a patent airway
Ensure adequate ventilations & oxygenation
Control external bleeding

49. Crystalloid solution (Nacl / ringer lactate) Colloid solution ( Albumin, hydroxyethyl starch, dextran & gelatin)

50. Management according to stages Class l – blood loss is upto 15%, heart rate is slightly elevated or normal. No requirement of blood Class ll – 15-30% blood loss, clinically manifested trachycardia, tachypnea Mostly stabilized with crystalloid solution, acc. to situation few may require blood

51. Class lll – 40% blood loss, significant drop in blood pressure & changes can be seen in mental status . Stop bleeding, blood transfusion Class lV – More than 40% blood loss , it becomes life threatening Stop the bleeding, rapid blood transfusion & surgical intervention depending on the initial fluid response..

52. Treatment of shock Guidelines – to treat the cause , to improve cardic function, to improve tissue perfusion. Eg .arrest hemorrhage – drain pus Fluid replacement ( a large cannula inserted to foreman vein for infusion, plasma, normal saline, ringer lactate,)

53. Correct acid- base balance Steroids ( one-life saving ) 500-1000mg of hydrocortisone can be given ( improves perfusion, reduces the capillary leakage) Common medications +ve ionotropic – amrione, norepinephrine, dopamine -ve chronographic agents- atropine, isoproterenol Increased perload- epinephrine & norepinephrine Decreased perload- nitoprusside, nitroglycerin

54. Questions Short note on Hemorrhagic shock ? Define shock, enumerate types & management of Hemorrhagic shock? Define & classify shock. How will access & treat the cause of Hemorrhagic shock. Mention the complication of shock transfusion? Describe Shock & it’s classification ? Management of Hemorrhagic shock?