Shock - Presentation by us (Rivin,Dhara,Arun)

Shock is a life-threatening condition that occurs when the body is not getting enough blood flow. Lack of blood flow means the cells and organs do not get enough oxygen and nutrients to function properly.

1. Shock Arun M. Boban Dharanidharan Jeyaseelan W.P. Rivindu H. Wickramanayake Tbilisi State Medical University, Georgia 3 rd Year 2 nd Semester – Group no. 04a 2017 November

2. Shock Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism. Imbalance between the supply and demand for O 2 and nutrients

3. Low blood flow - Cardiogenic - Hypovolemic Mal-distribution of blood flow - Septic - Anaphylactic - Neurogenic Classification of shock

4. Low Blood Flow Cardiogenic Shock Definition Systolic or diastolic dysfunction Compromised cardiac output (CO) Next ;

5. Continued ; Precipitating causes Myocardial infarction Cardiomyopathy Blunt cardiac injury Severe systemic or pulmonary hypertension Cardiac tamponade Myocardial depression from metabolic problems Next ;

6. Early manifestations Tachycardia Hypotension Narrowed pulse pressure ↑ Myocardial O 2 consumption Next ; Continued ;

7. Physical examination Tachypnea, pulmonary congestion Pallor; cool, clammy skin Decreased capillary refill time Anxiety, confusion, agitation ↑ in pulmonary artery wedge pressure Decreased renal perfusion and UO Continued ;

8. Hypovolemic Shock Absolute hypovolemia: - Loss of intravascular fluid volume Hemorrhage GI loss (e.g., vomiting, diarrhea) Fistula drainage Diabetes insipidus Hyperglycemia Diuresis Next ;

9. - Results when fluid volume moves out of the vascular space into extravascular space (e.g., interstitial or intra- cavitary space) Termed third spacing Relative hypovolemia Next ; Continued ;

10. Response to acute volume loss depends on - Extent of injury or insult - Age - General state of health - Anxiety - Tachypnea - Increase in CO, heart rate - Decrease in stroke volume, PAWP, UO If loss is >30%, blood volume is replaced Clinical manifestations Continued ;

11. Mal-distribution of Blood Flow Neurogenic Shock Hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above and can last up to 6 weeks Can be in response to spinal anesthesia Results in massive vasodilation leading to pooling of blood in vessels Next ;

12. Hypotension Bradycardia Temperature dysregulation (resulting in heat loss) Dry skin Poikilothermia (taking on the temperature of the environment Clinical manifestations Continued ;

13. Anaphylactic Shock Massive vasodilation Release of mediators ↑ Capillary permeability Acute, life-threatening hypersensitivity reaction Next ;

14. Anxiety, confusion, dizziness Sense of impeding doom Chest pain Incontinence Swelling of the lips and tongue, angioedema Wheezing, stridor Flushing, pruritus, urticarial Respiratory distress and circulatory failure Clinical manifestations Continued ;

15. Septic Shock Sepsis: Systemic inflammatory response to documented or suspected infection Severe sepsis = Sepsis + Organ dysfunction Septic shock = Presence of sepsis with hypotension despite fluid resuscitation + Presence of tissue perfusion abnormalities Mortality rates as high as 50% Primary causative organisms - Gram-negative and gra m-positive bacteria - Endotoxin stimulates in flammatory response Next ;

16. ↑ Coagulation and inflammation ↓ Fibrinolysis Formation of microthrombi Obstruction of microvasculature Hyperdynamic state: Increased CO and decreased SVR Clinical manifestations Next ; Continued ;

17. Tachypnea/hyperventilation Temperature dysregulation ↓ Urine output Altered neurologic status GI dysfunction Respiratory failure is common Continued ;

18. Stages of Shock Initial Stage Usually not clinically apparent Metabolism changes from aerobic to anaerobic - Lactic acid accumulates and must be removed by blood and broken down by liver - Process requires unavailable O 2

19. Compensatory St age Clinically apparent - Neural - Hormonal - Biochemical compensatory mechanisms Attempts are aimed at overcoming consequences of anaerobic metabolism and maintaining homeostasis Impaired GI motility - Risk for paralytic ileus Cool, clammy skin from blood - Except septic patient who is warm and flushed

20. Progressive Stage Begins when compensatory mechanisms fail Aggressive interventions to prevent multiple organ dysfunction syndrome (MODS) Movement of fluid from pulmonary vasculature to interstitium Pulmonary edema Bronchoconstriction ↓ Residual capacity Next ;

21. Fluid moves into alveoli Edema Decreased surfactant Worsening V/Q mismatch Tachypnea Crackles Increased work of breathing Next ; Continued ;

22. Myocardial dysfunction results in Dysrhythmias Ischemia Myocardial infarction End result: Complete deterioration of cardiovascular system Next ; Continued ;

23. Ulcers Bleeding Risk of translocation of bacteria Decreased ability to absorb nutrients Mucosal barrier of GI system becomes ischemic Next ; Continued ;

24. Liver fails to metabolize drugs and wastes Jaundice Elevated enzymes Loss of immune function Risk for DIC and significant bleeding Acute tubular necrosis/acute renal failure Continued ;

25. Refractory Stage Exacerbation of anaerobic metabolism Accumulation of lactic acid ↑ Capillary permeability Profound hypotension and hypoxemia Tachycardia worsens Decreased coronary blood flow Cerebral ischemia Failure of one organ system affects others Recovery unlikely

26. Diagnostic Studies Thorough history and physical examination No single study to determine shock Blood studies - Elevation of lactate - Base deficit 12-lead ECG Chest x-ray Hemodynamic monitoring

27. Collaborative Care Cardiogenic Shock Restore blood flow to the myocardium by resto ring the balance between O 2 supply and demand Thrombolytic therapy Angioplasty with stenting Emergency revascularization Valve replacement Hemodynamic monitoring Drug therapy (e.g., diuretics to reduce preload) Circulatory assist devices (e.g., intra-aortic balloon pump, ventricular assist device)

28. Hypovolemic Shock Management focuses on stopping the loss of fluid and restoring the circulating volume Fluid replacement is calculated using a 3:1 rule (3 ml of isotonic crystalloid for every 1 ml of estimated blood loss)

29. Septic Shock Fluid replacement (e.g., 6 to 10 L of isotonic crystalloids and 2 to 4 L of colloids) to restore perfusion Hemodynamic monitoring Vasopressor drug therapy; vasopressin for patients refractory to vasopressor therapy Intravenous corticosteroids for patients who require vasopressor therapy, despite fluid resuscitation, to maintain adequate BP Next ;

30. Antibiotics after obtaining cultures (e.g., blood, wound exudate, urine, stool, sputum) Drotrecogin alfa ( Xigris ) - Major side effect: Bleeding Glucose levels <150 mg/dl Stress ulcer prophylaxis with histamine (H 2 )-receptor blockers Deep vein thrombosis prophylaxis with low-dose unfractionated heparin or low-molecular-weight heparin Continued ;

31. Neurogenic Shock In spinal cord injury: Spinal stability Treatment of the hypotension and bradycardia with vasopressors and atropine Fluids used cautiously as hypotension is generally not related to fluid loss Monitor for hypothermia

32. Anaphylactic Shock Epinephrine, diphenhydramine Maintaining a patent airway Nebulized bronchodilators Endotracheal intubation or cricothyroidotomy may be necessary Aggressive fluid replacement Intravenous corticosteroids if significant hypotension persists after 1 to 2 hours of aggressive therapy

33. FIRST AID If you suspect a person is in shock, call 911. Then immediately take the following steps: Lay the person down and elevate the legs and feet slightly, unless you think this may cause pain or further injury. Keep the person still and don't move him or her unless necessary. Begin CPR if the person shows no signs of life, such as breathing, coughing or movement . Next ;

34. Loosen tight clothing and, if needed, cover the person with a blanket to prevent chilling. Don't let the person eat or drink anything. If the person vomits or begins bleeding from the mouth, turn him or her onto a side to prevent choking, unless you suspect a spinal injury Continued ;

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