Shock and it's clinical importance in various conditions

Shock and it's clinical importance in various conditions
Shock is a serious condition

1. Shock By UNIT M V11 CHEIF professor:DR.PEER MOHAMMED Sir Assistant professors:dr.satish Kumar sir DR.VIGNESH sir Dr.vinoth kannan Sir

2. Definition: Shock is defined as a state of cellular and tissue hypoxia due to either reduced oxygen delivery, increased oxygen consumption, inadequate oxygen utilisation , or a combination of these processes

3. Pathophysiology of shock:

4. APPROACH TO PATIENT WITH SHOCK: Shock possibility should be considered in patients presenting with new organ dysfunction or hypotension Early recognition can result in early treatment in reversible state of shock Determine the type of shock by history, physical examination, diagnostic tests, chest xrays , electrocardiogram, POCUS

5. History: Distributive shock:fever and history suggestive of focal site of infection(cough, sputum, abdominal discomfort, diarrhea, dysuria) Anaphylactic shock(type of distributive shock) : pruritis , hives, dyspnoea , facial edema Cardiogenic shock: Exertional chest discomfort, patients with arrythmias presents with palpitations and syncope hypovolemic shock:trauma and GI BLEED OBSTRUCTIVE SHOCK: tearing chest or back pain in hypertensive patients indicating aortic dissection pulmonary thromboembolic pts presents with assymetric leg swellings, acute onset chest pain with dysnea and in immobile patients

6. PHySICAL EXAMINATION: Hypotension (SBP<90mmhg,MAP<65mmhg) tachycardia Tachypnea Encephalopathy features indicate decompensated shock Oliguria(<0.5ml/ kgper hour)

7. Cold Calmmy skin, delayed capillary refill time, narrow pulse pressure seen in Cardiogenic, obstructive and hypovolemic shock cardiac and obstructive shock have elevated jvp differentiated from hypovolemic shock with reduced jvp Warm peripheral extremities, capillary refill time(<2sec),large pulse pressure seen in distributive shock Cardiogenic shock presents with peripheral edema

8. SHOCK INDEX:HR/SYSTOLIC BP SI:0.5-0.7(NORMAL) SI:>0.9(transfusion requirement indicated) Modified shock index:HR /MAP qSOFA : SBP<100 RR>22 ALTERED SENSORIUM qSOFA >2 indicates shock

9. Diagnostic testing:

10. Stages of shock: Non progressive phase:compensated stage, normal mechanisms will cause recovery. (baroreceptor reflexes, angiotebsin secretion by the kidneys, vasopressin-constriction of peripheral arteries and veins Progressive phase:the phase characterised by tissue hypoperfusion and worsening circulatory and metabolic abnormalities including lactic acidosis leading to metabolic acidosis irreversible phase:the phase during which damage is so severe that, even if perfusion is restored, survival is not possible

11. Classification of shock:

12. Hypovolemic shock: Shock due to hypovolemia… with reduced CO, ELEVATED SVR, LOW CVP AND PCWP CAUSES:hemorrhagic non hemorrhagiC

13. Clinical features of hypovolemic shock: Patient becomes pale with cold calmmy skin Hypotension Weak, rapid pulse Increased respiratory rate Seating Increased thirst Decreased urinary output Metabolic acidosis restlessness

14. MANAGEMENT OF HYPOVOLEMIC SHOCK: ABC(AIRWAY,BREATHING,CIRCULATION CONTROL HEMAORRHAGE OBTAIN IV ACESS AND RESUSCITATE WITH FLUIDS AND BLOOD -2 IV lines of 18 gauge must be put in adult patients -a fluid bolus of 30ml/kg(1-2litres)over 30 to 60mins 2-3LITRES CRYSTALLOIDS can be administered in first 3 hrs Normal saline or ringer lactate Packed RBCs Along with crystalloid fluids in hemorrhagic shock Vasopressors are not indicated in early management of hypovolemic shock.. Fluid resuscitation should be the first line of management

15. PREFFERED FLUIDS: Despite the superiority of colloid fluids for increasing plasma volume and promoting cardiac output… . CRYSTALLOIDS are the most preferred resuscitation fluids.. Reason being low cost and lack of documented survival benefit with colloids Favoured crystalloid is ringer lactate which does not produce metabolic acidosis that occurs with normal saline

16. ESTIMATING RESUSCITATION VOLUME:

17. Clinical findings of good perfusion: Mean arterial pressure(>65mmhg) Urine output>0.5ml/kg/ hr Decreasing lactate:lactate clearance >10% Normalizing ph Improving level of consciousness Cvp 8to 12mmhg Central venous oxy hemoglobin saturation>70 percent

18. OBSTRUCTIVE SHOCK: Characterised by reduced CO due to extracardiac pulmonary vascular etiology or mechanical process impairing output Causes: tension pneumothorax, cardiac tampon ade , restrictive pericarditis, fat embolism, pulmonary embolism, venous air embolism, aortic dissection Raised CVP and PCWP Reduced cardiac output Raised SVR

19. Management: Need to treat etiology Tension pneumothorax treated by needle decompression /chest tube Cardiac tamponade Treated by pericardial tap Pulmonary embolus Treated by anticoagulation(heparin)

20. Case scenarois : A 50 Yr old male patient Brought with clo loose stools and vomiting multiple episodes since 2 days with cold peripheries, Weak rapid pulse and intense thirst and sunken eyes A 35 Yr old female with chest pain and shortness of breathe sao2 82%,bp80/60elevated jvp , ecg with S1Q3T3 CT CHEST:MASSIVE SADDLE PULMONARY EMBOLISM