SHOCK: Types, investigations, management

Medical LICENTIATE EMERSON

1. SHOCK cuz 1 Bsc.CS 14-May-22

2. DEFINITION A CONDITION CHARACTERIZED BY A SIGNIFICANT DECREASED SYSTEMIC PERFUSION RESULTING IN REDUCED OXYGEN DELIVERY… OR SIMPLY AN IMBALANCE BETWEEN OXYGEN DELIVERY AND CONSUMPTION. 2 Bsc.CS 14-May-22

3. TYPES OF SHOCK HYPOVOLEMIC CARDIOGENIC DISTRIBUTIVE OBSTRUCTIVE 14-May-22 Bsc.CS 3

4. Hypovolemic shock Due to diminished blood volume 14-May-22 Bsc.CS 4

5. Cardiogenic shock Due to inefficient myocardial function 14-May-22 Bsc.CS 5

6. Distributive shock Septic shock; Neurogenic shock; due to peripheral vasodilatation, reduced peripheral resistance and peripheral pooling of blood secondary to fracture spine. Commonly with warm extremities and bradycardia Anaphylactic shock; due to antigen antibody reaction that also leads to peripheral pooling of blood e.g MAY FOLLOW ADMINISTRATION OF PENICILLIN, ANTIGEN-ANTIBODY “ IgE ” REACTION LEADS TO RELEASE OF HISTAMINE THAT LEADS TO;- BRONCHOSPASM.- LARYNGEAL EDEMA.- MASSIVE VASODILATATION. 14-May-22 Bsc.CS 6

7. OBSTRUCTIVE SHOCK CARDIAC TAMPONADE & PULMONARY EMBOLISM & TENSION PNEUMOTHORAX 14-May-22 Bsc.CS 7

8. STAGES OF SHOCK >COMPENSATED SHOCK >DECOMPENSATED SHOCK >IRREVERSIBLE SHOCK 8 Bsc.CS 14-May-22

9. COMPENSATED SHOCK COMPENSATED MECHANISMS ATTEMPT TO NORMALIZE BLOOD PRESSURE BP IS NORMAL, TACHYCARDIA MILD TACHYPNEA; REDUCED CRT, ORTHOSTATIC CHANGES IN BP AND OR PULSE, IRRITABLE , COMPENSATED BY RAAS . 14-May-22 Bsc.CS 9

10. DECOMPENSATED SHOCK COMPENSATED MECHANISMS FAILS HYPOTENSION DEVELOPS, INCREASED TACHYCARDIA(THIN THREADY PULSE) AND TACHYPNOEA REDUCED URINE OUTPUT, ALTERED MENTAL STATE, COLD PERIPHERIES 10 Bsc.CS 14-May-22

11. IRREVERSIBLE SHOCK PROLONGED DECOMPENSATED SHOCK PERMANENT CELLULAR DAMAGE AND MODS DEVELOP NO RECOVERY DEATH IS DUE TO REFRACTORY ACIDOSIS, BRAIN AND HEART ISCHAEMIA 14-May-22 Bsc.CS 11

12. IDENTIFICATION OF SHOCK GENERAL SIGNS TACHYCARDIA WITH HR> 100 bpm BLOOD PRESSURE; MAY BE LOW OF NORMAL IN COMPENSATORY SHOCK TACHYPNOEA ALTERED MENTAL STATUS PULSE PRESSURE <30mmhg COLD CLAMMY SKIN REDUCED URINE OUTPUT 14-May-22 Bsc.CS 12

13. GENERAL Criteria FOR A SHOCKED PATIENT REDUCED LEVELS OF CONSCIUOSNESS/ILL LOOKING HR>100/ min RR>24/min PaCO 2 <32mmhg LACTATE LEVELS >4mmol/L BASE DEFICIT -5mEq/L Urine output <0.5ml/hour SBP <90 14-May-22 Bsc.CS 13

14. Target history (systemic) Rs; chest pain (mi), shortness of breath ( ccf , pericardial/pleural effusions etc ) Gi; vomiting/diarrhea, pancreatitis, bowel etc GUT; ECTOPIC PREGNANCY, MSS; BACK PAIN (RAPTURED AAA) TRAUMA; PHYSICAL FIGHTS, FALLS etc IMMUNOCOMPROMISED; SEPSIS HAEMORRHAGE; MELAENA, HAEMATEMESIS, HAEMOPTYSIS, MEDICATION; STEROIDS, CARDIODEPRESSIVE EXPOSURE ; FUMES, HYPOTHERMIA 14-May-22 Bsc.CS 14

15. PHYSICAL EXAMINATION G/E –GCS, BP, PULSE, CYANOSIS, PUPILS, REFLEXES, EVIDENCE OF TRAUMA, RAISED JVP, ALCOHOL SMELL CHEST; RALES, WHEEZING, RED. AE CVS; MUFFLED HS, NEW MURMURS P/A; TENDERNESS, TRAUMA, PERITONITIS RECTAL; BLOOD 14-May-22 Bsc.CS 15

16. INVESTIGASTIONS BLOOD SUGARS, FBC/DC, HB, ABG, ELECTROLYTES, UREA AND CREATINE, LFT SEPSIS SCREEN; BLOOD CULTURES, URINE/STOOL MCS, MPS CXR; CARDIOMEGALY, ALVEOLAR INFILTRATES ECG; MANDATORY IN ELDERLY R/O MI URINALYSIS; GLUCOSE, KETONES, INFECTION EMERGENCY U/S TOXICOLOGY; PRN 14-May-22 Bsc.CS 16

17. GENERAL PRINCIPLES OF MANAGEMENT ROUTINE; BP, PULSE, PULSE OXIMETRY, INPUT/OUTPUT SHOCK INDEX; HR/SBP >0.9 SIGNIFIES IMPENDING SHOCK ARTERIAL VENOUS BGs END TIDAL CO 2 LACTATE LEVELS; PROGNOSTIC INDICATOR, FAILURE TO REDUCE LACTATE TO LESS THAN 50% AFTER FULL RESUSCITATION MAY SIGNIFY MAY SIGNIFY REFRACTORY SHOCK. AIM FOR LACTATE LEVELS <2mmol/L 14-May-22 Bsc.CS 17

18. MANAGEMENT ABC s >CALL FOR HELP >AIRWAY CLEAR, SUPPLEMENTAL OXYGEN, ASSESS NEED FOR VENTILATION WHICH REDUCE WORK OF BREATHING >2 LARGE IV ACCESS. ONCE IV ACCESS IS OBTAINED, INITIAL FLUID RESUSCITATION WITH AN ISOTONIC CRYSTALLOID, SUCH AS LACTATED RINGERS SOLUTION OR NORMAL SALINE. AN INITIAL BOLUS OF 1-2L IS GIVEN IN AN ADULT, FOLEYS CATHETER, IVF s TO MAINTAIN U/O> 0.5mls/Kg/min PATIENTS SHOULD BE MONITORED FOR SIGNS OF VOLUME OVERLOAD; THESE INCLUDE DYSPNEA, PULMONARY RALES, AND PULMONARY EDEMA ON THE CHEST RADIOGRAPH. IMPROVEMENT, STABILIZATION, AND NORMALIZATION IN THE PATIENT’S MENTAL STATUS, HEART RATE, BP, CAPILLARY REFILL, AND URINARY OUTPUT INDICATE ADEQUATE VOLUME RESUSCITATION. 14-May-22 Bsc.CS 18

19. >PRESSORS IF EVIDENCE OF CARDIOGENIC SHOCK OR IF FLUID RESUSCITATION INEFFECTIVE ie >60ml/Kg, DOPAMINE IS THE AGENT COMMONLY USED FOR THIS PURPOSE. TREATMENT USUALLY BEGINS AT A RATE OF 5.0-10mcg/Kg/min WITH INTRAVENOUS ADMINSTRATION, AND THE INFUSION IS ADJUSTED ACCORDING TO BP AND OTHER HEMODYNAMIC PARAMETERS. ADRENALINE (1:1000) 5mg IN 500mls DNS @12drops/minute CAN EQUALLY BE USED. BLOOD SHOULD BE SOURCED AND TRANSFUSION COMMENCED IF EVIDENCE OF BLEEDING, CLINICALLY PALE OR HEMOGRAM SUGGESTS ANAEMIA. IN THE ABSENCE OF WHOLE BLOOD MANY SUBSTANCES MAY BE USED AS HUMAN PLASMA ALBUMIN AND DEXTRAN IN SUSPECTED SEPTIC SHOCK. INITIAL BROAD SPECTRUM ANTIBIOTICS TO COVER GRAM POSITIVE, NEGATIVE AND ANAEROBIC ORGANISMS. ANTIBIOTICS MUST BE GIVEN PARENTERALLY IN DOSES ADEQUATE TO ACHIEVE BACTERICIDAL SERUM LEVELS GIVE ADRENALINE IM 0.5mg ( ie 0.5mL OF 1:1000). REPEAT EVERY 5min, IF NEEEDED AS GUIDED BY BP, PULSE, AND RESPIRATORY FUNCTION, UNTIL BETTER. IV HYDROCORTISONE (IS AS IMPORTANT). ANTIHISTAMINES AND MAY NEED ENDOTRACHEAL INTUBATION AND NURSING FROM ICU DEPENDING ON THE SEVERITY. 14-May-22 Bsc.CS 19

20. END POINTS URINE OUTPUT > 0.5 mls/Kg/hour CVP; 8-12mmHg MAP; 65-90 CV 0 2 SAT; > 70% 14-May-22 Bsc.CS 20

21. REFRACTORY SHOCK NO RESPONSE TO PRESSORS OR IVF s FOR >1 HOUR THINK OF ADRENAL CRISIS (LOW SODIUM, HIGH OR NORMAL K), GIVE DEXAMETHASONE 4mg IV >HYDROCORTISONE 200mg START THEN 50mg TDS or QID EXCLUDE PNEUMOTHORAX CARDIAC TAMPONADE CONCEALED BLEEDING MEDICATION ALLERGIES 14-May-22 Bsc.CS 21

22. CONTINUOUS MONITORING VITAL SIGNS (TEMPERATURE, PULSE, BP AND RR) AND ECG URINE OUTPUT ABG s, REPEATED BLOOD CULTURE, CBC, COAGULATION PROFILE & ORGAN FAILURE. STRICT CONTROL OF BLOOD SUGAR HAS BEEN PROVED TO INCREASE SURVIVAL. PROPHYLAXIS AGAINST DVT AND STRESS ULCERS. 14-May-22 Bsc.CS 22

23. COMPLICATIONS ACUTE KIDNEY INJURY ACUTE RESPIRATORY DISTRESS SYNDROME DISSEMINATED INTRAVASCULAR COAGULATION ARRHYTHMIAS NOTE THAT; MANAGEMENT OF SHOCK SHOULD BE DIRECTED AT THE CAUSE. A PROPER HISTORY AND PHYSICAL EXAMINATION WILL HELP DIRECT TO THE CAUSE OF SHOCK 14-May-22 Bsc.CS 23

24. Ideas have a short shelf life—that’s why we must act before the expiry date THE END THANK YOU 24 Bsc.CS 14-May-22