shock-basicprinciplesinsurgery-221017132732-cbe19616.pptx

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1. AN OVRVIEW SHOCK BASIC PRINCIPLES

2. SHOCK Objectives Definition Types Etiology Pathophysiology Stages Clinical features- Symptoms & Signs Investigations Treatment Prognosis Treatment Algorithm

3. SHOCK- Definition Shock is defined as a state of cellular and tissue hypoxia due to either reduced oxygen delivery, increased oxygen consumption, inadequate oxygen utilization, or a combination of these processes. This most commonly occurs when there is circulatory failure manifested as hypotension ie , reduced tissue perfusion Shock is initially reversible but must be recognized and treated immediately to prevent progression to irreversible organ dysfunction. "Undifferentiated shock" refers to the situation where shock is recognized but the cause is unclear

4. SHOCK- Types Hypovolemic Cardiogenic Obstructive - Tension pneumothorax - Massive pulmonary embolism - Cardiac tamponade Distributive - Septic - Anaphylactic - Neurogenic

5. SHOCK- Etiology

6. SHOCK- Etiology Hypovolemic Shock- Causes Hemorrhage - External including GIT - Internal # Chest # Abdomen # Pelvis # Retroperitoneum # Long bones Vomiting Diarrhoea Diuresis Burns

7. SHOCK- Etiology Cardiogenic Shock- Causes Myocardial infarction Myocardial contusion Myocarditis Cardiac arrythmias - Unstable tachy-arrythmias - Unstable brady-arrythmias Inotropic drugs overdosage - Beta blockers - Calcium channel blockers

8. SHOCK- Etiology Obstructive Shock- Causes Tension pneumothorax Cardiac tamponade Massive PE

9. SHOCK- Etiology Distributive Shock- Causes Septic shock Anaphylactic shock Neurogenic shock

10. SHOCK- Pathophysiology

11. SHOCK- Pathophysiology Hypovolemic Shock

12. SHOCK- Pathophysiology Septic Shock

13. SHOCK- Pathophysiology Cardiogenic Shock Important facts BP= CO x SVR CO= HRx SV SV is volume of blood pumped by the heart per contraction. This is decided by preload, myocardial contractility and afterload. Preload- is the ventricular wall tension at the end of diastole. Afterload is the ventricular wall tension at the end of systole.

14. SHOCK- Pathophysiology Neurogenic Shock

15. SHOCK- STAGES

16. SHOCK- Clinical Features Symptoms Assessment of severity - Dyspnea - Confusion - Light-headedness - Drowsiness - Oliguria/anuria Symptoms of the cause Signs Airway - May be compromised by reduced conscious level Breathing: Hypoxia secondary to - Airway compromise - Kussmal’s brathing  Hyperventilation to compensate for metabolic acidosis Circulation: - Cold & pale extremities - Prolonged capillary refill time CRT > 2secs - Tachycardia - Oliguria/Anuria Disability: - Confusion - Drowsiness - Unconciousness

17. SHOCK- Investigations Blood including blood gas to check pH and lactate ECG & CXR CVP, PCWP, CO & SVR Echocardiogram In trauma patients - Pelvic X-ray - CT- TAP - e-FAST scan

18. SHOCK- Treatment Assess the patient from an ABCDE perspective Maintain a patent airway Use manoeuvres, adjuncts, supraglottic or definitive airways as indicated and suction any sputum or secretions Deliver high flow oxygen 15L/min via reservoir mask to keep sats over 94% Attach monitoring - Pulse oximetry and non-invasive blood pressure - Three-lead cardiac monitoring Request 12 lead ECG and portable CXR Obtain large-bore intravenous (IV) access and take bloods including blood gas to check pH and lactate Fluid resuscitation IV Urethral catheterisation and fluid balance monitoring aiming for a urine output >0.5 ml/kg/hour If BP fails to respond consider referral to HDU/ICU for Central line insertion with central venous pressure (CVP) and central venous oxygen saturation (ScvO2) monitoring Arterial line insertion and invasive arterial BP monitoring Vasopressor and/or inotrope infusion Initial management of shock

19. SHOCK- Treatment Further management of shock Identify and treat the cause Haemorrhagic shock Identify the source(s) of bleeding and achieve haemorrhage control e.g. direct compression, pelvic binder, splinting of long bone fractures, surgical ligation of bleeding vessels Restoration of adequate circulating volume Cross-match blood and activate the major haemorrhage protocol Transfuse O negative blood initially, followed by type-specific and fully cross-matched blood as soon as it is available; aim for permissive hypotension Correct coagulopathy by transfusion of platelets, FFP & cryoprecipitate as appropriate RBC: FFP ratio should be between 1:1 and 1:2, the optimum ratio is uncertain. The key is to give FFP early with RBC. Cryo if fibrinogen<1.5. Antibiotics and source control for septic shock Adrenaline 0.5 mg intramuscular (IM) for anaphylactic shock Needle thoracocentesis and intercostal chest drain insertion for tension pneumothorax Pericardiocentesis and thoracotomy for cardiac tamponade Thrombolysis for massive PE Synchronised direct current (DC) cardioversion for unstable tachyarrhythmias Pacing for unstable bradyarrhythmias

20. SHOCK- PROGNOSIS

21. SHOCK- Treatment

22. SHOCK- Treatment

23. Peripheral Arterial Diseases(PAD)