shock by d updated new context from baily.pptx

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1. SHOCK By : Duveri Deepika

2. OVERVIEW Definition. Physiology . Pathophysiology . Types of shock. Approach to a shock patient.

3. Why do we need to know about shock?? SHOCK IS MOST COMMON AND MOST IMPORTANT CAUSE OF DEATH IN SURGICAL PATIENTS.

4. DEFINITION Shock is a systemic state of low tissue perfusion that is inadequate for normal cellular respiration.

5. PHYSIOLOGY Cell is the structural and functional unit of the body. For the functioning of cell - oxygen and glucose is required. Perfusion depends on – pump , vessels, Volume .

6. Pathophysiology

7. Cellular : metabolic acidosis due to anaerobic metabolism. Cell lysis due to auto Digestive enzymes by lysosomes . Microvascular : damage of endothelium due to OFR. Systemic : CVS : baroreceptors - catecholamines . RS : Compensatory Respiratory alkalosis to MA. Renal : RAAS - sodium and water reabsorption . ENDOCRINE : ADH -Na and water reabsorpbed CORTISOL.

8. Severity of shock

9. Types of shock Hypovolemic . Cardiogenic . Obstructive. Distributive - septic, anaphylactic,neurogenic . Endocrine. Others - poisons,hypothermia,psychogenic .

10. HYPOVOLEMIC SHOCK

11. Hypovolemic shock NON HAEMORRHAGIC CAUSES Git : diarrhea,Vomiting,fistula,biliary loss,ng suction. Renal : Dm,diuretics,osmotics,Renal failure. Skin : intense effort,heat stroke,burns. Third space : peritonitis,obstruction,Ascites, pancreatitis,effusions.

12. 2. HAEMORRHAGIC CAUSES Wounds Hemetemesis , melena , hemoptysis , epistaxis . Hemothorax,hemoperitoneum . Fluid loss is absolute or relative( third space loss).

13. CLINICAL PRESENTATION Pale,cool and clammy skin. Anxiety,dizziness,altered mental status. Thirsty, dry mucous membranes. Delayed capillary refill. Tachycardia,Tachypnoea . Wide Pulse pressure. Weak thready and rapid Pulse. Decreased urine output.

14. MANAGEMENT Airway - secure. Breathing - oxygen supply. Circulation. Secure iv access by 2 short and wide bore 18G green cannulas . Warm crystalloids - 1L of RL/NS @20ml/kg. Dynamic fluid response is observed and categorized into : Responders. Transient responders. Non responders.

15. BLOOD Crash 2 trial (BP<90 mmhg ; PR >110/ min) - 1gm tranexamic acid in 10 mins followed by 1gm in 8 hrs. Monitor for Acute traumatic coagulopathy -avoid crystalloids due to risk of dilutional coagulopathy - so give blood. Blood group O negative for reproductive females and O positive for males and post reproductive females. Balanced resuscitation ( 1:1:1 prbc : plt : plasma). Permissible hypotension(70-90) maintained to prevent rebleeding and hypoxia. Massive transfusion protocol ( >10u in 24hrs or >4 units in a hour ). Replacement of clotting factors if required.

16. STOP BLEEDING External - pressure, splinting, binders,tourniquet . Internal - identify the source of bleeding before landing into lethal triad - prevented and managed by DCS.

17. CARDIOGENIC SHOCK

18. Causes Systolic dysfunction - MI,Myocardial depressants ( ccb , bb) Diastolic dysfunction - restrictive cardiomyopathy . Structural and valvular abnormalities. Arrhythmias.

19. Clinical presentation Pallor,cold and clammy skin. Central and peripheral cyanosis. Tachypnoea , tachycardia, hypotension. Increased jvp,dyspnoea . Confused,agitated . Decreased urine output.

20. MANAGEMENT Oxygen therapy. Inotropes Norepinephrine - increase DBP there by increasing coronary perfusion. Dopamine . Dobutamine . Refractory cases - IABP,Ventricular assist device. Diuretics - helps in decreasing preload.

21. OBSTRUCTIVE SHOCK

22. Cause and management Cardiac tamponade. Constrictive pericarditis. Tension pneumothorax. Massive pulmonary embolism. Aortic stenosis. Pericardiocentesis. Pericardial stripping. Needle/icd. Thrombolysis / embolectomy Trans aortic valve repair.

23. SEPTIC SHOCK

24. Definition and terms SIRS (Systemic inflammatoryresponse syndrome ) >/=2 A.Temperature >38 or <35. B. Respiratory rate >20/min (paco2 = < 32mmhg). C. Heart rate - >90/ min. D. TLC - >12000 OR < 4000. SEPSIS - SIRS + suspected or confirmed infection. SEPTIC SHOCK - SEPSIS + refractory hypotension + hypoperfusion . MODS - Multi organ dysfunction syndrome. (>2 organ systems).

25. Causes Bacteria - gram positive - strep,staph,clostridium,pneumpcocci . - gram negative (MC) - klebsiella , enterobacter,serratia , proteus , Pseudomonas,bacteroides . Viruses and Fungi causes septic shock in immunocompromied .

26. SOURCE ENDOGENOUS SKIN - SSI GU - UTI RS - LRTI GIT - perforations, bowel surgery . EXOGENOUS Surgical instruments Drapes Imaging machines Staff.

27. Risk factors Age <10 or >70. Malnutrition , anemia Immunosuppressed . Malignancies DM , CLD, CRF. Catheterization Prolonged hospitalization Major surgeries,trauma , extensive burns

28. Net effect Hypovolemia. A - V shunting. Cardiac depression. DIC.

29. Clinical presentation EARLY STAGE (Compensated/warm shock) - not associated with hypovolemia . Febrile,chills and rigor. Warm,dry,flushed skin. Tachypnoea , tachycardia,Wide PP, Rapid bounding pulse. LATE STAGE ( Decompensated / cold shock ) - associated with hypovolemia . Altered sensorium . Hypothermia, hypotension. Feeble Pulse. Oliguria,jaundice . DIC.

30. Investigations Localise septic focus by thorough examination. Blood /sputum /urine /wound / endocervical / csf - culture and sensitivity. Chest/abdominal X-Ray. Usg . CT scan.

31. Management Fluid resuscitation. Oxygen therapy. Vasopressors A. Norepinephrine ( alpha1 and beta1 ). B. Phenylephrine. C. Norepinephrine + vasopressin. Antibiotics - broad spectrum. Nsaids - ibuprofen. Steroids - surviving sepsis campaign - hydrocortisone.

32. OFR Scavengers - sod,vit-c,allopurinol, alpha tocopherol. Glycemic control. Prophylaxis - AT III , Recombinant human activated protein- C. Removing septic focii - debridement, drainage, definitive surgery.

33. Complications ARDS. ARF. DIC. ENCEPHALOPATHY. LIVER FAILURE. MODS. DEATH.

34. Poor prognostic factors Advanced age. Immunosuppression. Resistant organism. Level of IL-6. Need for inotropes >24 hrs. Mods despite Treatment.

35. Markers of sepsis Procalcitonin a. Value of >2.0 IU/ml suggests severe sepsis. b. Best marker of sepsis. c. Best guide of antibiotic treatment. CRP. - highly sensitive.

36. qSOFA Score : quick sequential organ failure assessment score. A. Respiratory rate - > 22 / min. B. Confused mental status. C. BP - < 100 mmhg . A score of >2 suggests poor outcome.

37. SURVIVING SEPSIS GUIDELINES : Parameters to be met in first 6 hrs. CVP - 8 to 12. MAP - >/= 65 mmhg . URINE OUTPUT - >/= O.5 ml/kg/hr. MVOS - 65%. SVC Oxygen saturation - 70%.

38. Prevention Early recognition. Prompt treatment of infection. Meticulous surgical technique. Pre-op antibiotics. Aseptic techniques. Sterilization of equipment.

39. NEUROGENIC SHOCK

40. Causes High cervical spinal cord injury. Cephalad migration of spinal anesthesia . Deep GA (Depress vasomotor tone). Head injury.

41. Clinical presentation Paralysis. Hypotension. Bradycardia . Hypothermia. Warm and dry skin.

42. Management Spinal cord stability. Vasopressors . Atropine. Monitor hypothermia.

43. ENDOCRINE SHOCK

44. Hypothyroidism - decrease cardiac output - levothyroxine . Hyperthyroidism - reversible cardiomyopathy - methimazole,ptu . Acute adrenal insufficiency - steroids. A. Not tapered. B. Surgery for pt on corticosteroid.

45. ANAPHYLACTIC SHOCK

46. Management EPINEPHRINE : alpha1 ( vc ) , beta1 ( sbp ) , beta2 (BD). IM>> SC. 0.5 ml of 1 : 1000 solution. I.V ( 1: 10000) in non responsive shock. STEROIDS. DIPHENHYDRAMINE. NEBULIZED BRONCHODILATORS.

47. Approach to a shock patient

48. History. Physical examination . Investigations . Diagnosis and management. Parameters. Monitoring of shock. End points of resuscitation.

49. HISTORY Trauma Bleeding Fluid loss Fever and hypothermia. Chest pain, sob Allergen exposure Drugs Menstrual

50. PHYSICAL EXAMINATION GPE. GCS. Peripheries. Vital signs. Jvp . CVS RS Abdomen Rectal CNS

51. INVESTIGATIONS CBP, BGT, SCREENING. RFT. LFT. URINALYSIS . COAGULATION STUDIES . Glucose,lactate,calcium . ECG. CHEST X-RAY. PREGNANCY TEST. ABG. E- FAST.

52. Investigations Cardiogenic - cardiac enzymes, echo. Obstructive - CT , Echo. Anaphylactic - allergen testing. Neurogenic - CT , MRI.

53. PARAMETER HYPOVOLEMIC OBSTRUCTIVE CARDIOGENIC SEPTIC NEUROGENIC HR HIGH HIGH HIGH HIGH LOW RR HIGH HIGH HIGH HIGH LOW JVP LOW HIGH HIGH LOW LOW CO LOW LOW LOW HIGH HIGH MVOS LOW LOW LOW HIGH HIGH PERIPHERIES COOL COOL COOL WARM WARM

54. Parameters of shock Shock index - HR/SBP Indicates severity of shock. Aka hemodynamic stability indicator. >0.9 suggests decompensated Shock. 2. Modified Shock index - HR/MAP High - hypovolemic,cardiogenic,septic . Low - neurogenic . 3. ROPE - Pulse rate over pressure evaluation - PR/PP. >3 Suggests decompensated Shock.

55. URINE OUTPUT Best clinical indicator of tissue perfusion. Best indicator of fluid resuscitation. Normal values : Adults - >0.5 ml/kg/hr. Children - >1 ml/kg/hr.

56. CENTRAL VENOUS PRESSURE Normal value - 0 to 8. Measured by cvc and a manometer or transducer. fluid bolus (250 to 500 mL ) is infused rapidly over 5–10 minutes and cvp measured - increase of 2 to 5 cmh2o and becomes normal in 10 to 20 mins . A. No change - further resuscitation is required. B. Increased - implies cardiac insufficiency or overload. Best method to calculate amount of fluid to be given.

57. Base deficit Amount of base required to titrate a litre of whole arterial blood to a ph of 7.4. Normal value is -2 to +2 meq/l. Value below -2 suggests metabolic acidosis. Value above +2 suggests metabolic alkalosis.

58. Serum Lactate Best lab value to monitor tissue perfusion. Normal lactate value is 0.5 to 1 mmol/l. Value of <2 ~ good resuscitation. Value of >5 ~ bad resuscitation. Best to look for git and muscle perfusion.

59. Mixed venous oxygen saturation The percentage saturation of oxygen returning to the heart from the body is a measure of the oxygen delivery and extraction by the tissues. Measured in blood drawn from Central lines in right atrium or SVC. Normal range - 50 to 70 %. Low Mvos - hypovolemic and cardiogenic shocks. High Mvos - septic and neurogenic.

60. Thank you..