shock

Dr
YASIR ALSALAMAH
 INTRODUCTION

Shock is the most common and therefore the most important cause of death.
Death may occur rapidly , resulting from the consequences of organ ischaemia and
reperfusion injury.
It is important, therefore, that every surgeon understands the pathophysiology and
diagnosis of shock and haemorrhage, as well as the priorities for their management

Shock is a systemic state of inadequate tissue perfusion, which is inadequate

for normal cellular respiration.
No oxygen----- No energy--------- No life !
If perfusion is not restored in a timely fashion, cell death ensues.
 Pathophysiology of
shock

Sta
1

t
As perfusion to the tissues is

r
1 reduced, cells are deprived of oxygen
and must switch from aerobic to
2 anaerobic metabolism . ---- lactic
the accumulation of lactic acid in acid
the blood produces systemic 2
metabolic acidosis.

3
3
failure of the sodium/potassium pumps in
the cell membrane . Intracellular lysosomes
release autodigestive enzymes and cell lysis
ensues. Intracellular contents, including
potassium, are released into the
bloodstream
Pathophysiology of
shock
As tissue ischaemia progresses . activation of the immune and coagulation systems .
Hypoxia and acidosis activate complement and prime neutrophils, resulting in the
generation of oxygen free radicals and cytokine release . These mechanisms lead to
injury of the capillary endothelial cells .
allow fluid to leak out and tissue oedema ensues, exacerbating cellular hypoxia.
 compensatory mechanism of
shock
Cardiovascular

Renal
Decreased perfusion pressure in the kidney
01 As preload and afterload decrease there is a compensatory
baroreceptor response resulting in increased sympathetic activity
and release of catecholamines into the circulation.
leads to reduced filtration at the glomerulus
and a decreased urine output. The renin– This results in tachycardia and systemic vasoconstriction .
angiotensin–aldosterone axis is stimulated
Respiratory
resulting in further vasoconstriction and
increased sodium and water reabsorption 02 03 : The metabolic acidosis and increased
by the kidney . sympathetic response result in an increased
Endocrine respiratory rate and minute ventilation to
(antidiuretic hormone) is released from the increase the excretion of carbon dioxide-------
hypothalamus in response to decreased preload and respiratory alkalosis.
results in vasoconstriction and reabsorption of water
in the renal collecting system.
04
 Classification of shock

Hypovolaemic shock
a reduced circulating volume
due to haemorrhagic or non-haemorrhagic causes .
Hypovolaemia is probably the most common form of shock

Non-haemorrhagic causes include poor fluid intake (dehydration) and

excessive fluid loss because of vomiting, diarrhoea, urinary loss (e.g.
diabetes) . bowel obstruction or pancreatitis.
Haemorrhage must be recognised and managed aggressively to reduce
the severity and duration of shock and avoid death and/or multiple organ
failure.
Haemorrhage is treated by arresting the bleeding, and not by fluid
resuscitation or blood transfusion
 Classification of Hypovolaemic
shock
The adult human has approximately 5 litres of blood
The degree of haemorrhage can be classified into classes 1–4 based on the estimated blood loss required to produce
certain physiological compensatory changes

Treatment should therefore be based upon the degree of hypovolaemic shock according to vital signs, preload
assessment, base deficit and, most importantly, the dynamic response to fluid therapy. Patients who are non-
responders or transient responders are still bleeding and must have the site of haemorrhage identified and
controlled..
DIAGNOSIS

The diagnosis of Hypovolemic shock is initially based upon the history, physical examination
and laboratory studies should include analysis of the
: · CBC, electrolyte levels (eg, Na, K, Cl, HCO3, BUN, creatinine, glucose levels).

· Lactate , prothrombin time, activated partial thromboplastin time

· ABGs.
· urinalysis
PRINCIPLES OF MANAGEMENT :
The treatment of patients with hypovolemic shock often begins at an accident scene or at home .

The prehospital care team should work to prevent further injury

Direct pressure should be applied to external bleeding vessels to prevent further blood loss.

The cervical spine must be immobilized .

securing an adequate airway, ensuring ventilation, and maximizing circulation.

starting intravenous (IV) lines , large bore (14 G) ORANGE .

initial fluid resuscitation is performed with an isotonic crystalloid, such as lactated

Ringer solution . An initial bolus of 1-2 L is given in an adult .

blood should be sent for typed and cross-matched .

Always measure the urine output .

Vasopressors : Vasopressors (eg, norepinephrine) generally should not be administered, since they do not correct the
primary problem and, in the absence of adequate resuscitation, tend to further reduce tissue perfusion
 Cardiogenic shock

due to primary failure of the heart to pump blood

myocardial infarction, cardiac dysrhythmias, valvular heart disease, blunt myocardial injury and
cardiomyopathy .
Mortality rates for cardiogenic shock are 50% to 80%.
Acute, extensive MI is the most common cause of cardiogenic shock .

Sign and symptoms :

hypotension,
cool and mottled skin,
depressed mental status,
tachycardia, and diminished pulses.
dysrhythmia
DIAGNOSIS :

electrocardiogram and urgent echocardiography.

chest radiograph,
arterial blood gases,
electrolytes, complete blood count,
cardiac enzymes

Treatment
maintenance of adequate and
adjust fluid administration to avoid fluid overload
and development of cardiogenic pulmonary edema.
Electrolyte abnormalities, commonly hypokalemia and hypomagnesemia, should be corrected.
Pain is treated with IV morphine sulfate or fentanyl.
Significant dysrhythmias and heart block must be treated with antiarrhythmic drugs, pacing, or cardioversion

thrombolytic therapy
percutaneous transluminal coronary angiography .
 Obstructive shock

In obstructive shock there is a reduction in

preload because of mechanical obstruction
of cardiac filling. Common causes of
obstructive shock include cardiac
tamponade, tension pneumothorax,
massive pulmonary embolus and air
embolus.
SIGN AND SYMPTOMS :

respiratory distress (in an awake patient),

hypotension,
diminished breath sounds over one hemithorax, hyperresonance to percussion,
jugular venous distention, and shift of mediastinal structures to the unaffected side with tracheal deviation

Treatment :
Always treat the cause
pleural decompression ( chest tube )
pleural space can be decompressed with a large-caliber needle .
Beck’s triad for cardiac tamponade
hypotension,
muffled heart tones,
and neck vein distention

Tx : Pericardiocentesis
 Distributive shock ( septic ,
anaphylaxis , neurogenic )

Inadequate organ perfusion is accompanied by

vascular dilatation with hypotension, low
systemic vascular resistance, inadequate
afterload and a resulting abnormally high
cardiac output.
In septic shock bacterial products (endotoxins)
and the activation of cellular and humoral
components of the immune system.
septic shock is the result of dysfunction of the endothelium and vasculature secondary to
circulating inflammatory mediators .
hypotension results from failure of the vascular smooth muscle to constrict appropriately
, resistance to treatment with vasopressors .
the mortality rate for severe sepsis remains at 30% to 50%
findings include :
enhanced cardiac output,
peripheral vasodilation,
Fever
leukocytosis,
hyperglycemia, and tachycardia.
All due :
upregulation of of nitric oxide synthase in the vessel wall .
Before starting broad-spectrum antibiotic . We should draw blood sample for culture .
NEUROGENIC SHOCK

Loss of the sympathetic tone ( decrease SVR )

Causes : high spine or head injury .
Usually have decreased HR ,BP , Pink and warm skin .
Tx : volume 1st then epinephrin .
ANAPHYLACTIC SHOCK

An extreme , life-threatening allergic reaction to an antigen to which the body has become hypersensitive .

What are the signs and symptoms of anaphylactic shock?

Skin reactions, including hives and itching and flushed or pale skin and swelling of the face,
Low blood pressure (hypotension)
Constriction of the airways and a swollen tongue or throat, which can cause wheezing and trouble breathin
A weak and rapid pulse.
Nausea, vomiting or diarrhea.
Dizziness or fainting.
revision
 Thank you

Any questions ?
- In hypovolemic shock the decreased in CO is due to :
-
- A. Inadequate blood/plasma volume
- B. Reduced venous return
- C. Failure of myocardial pump
- D. A&B

- The heart pump is well but there is peripheral vasodilation:

- A. Hypovolemic shock
- B. Cardiogenic shock
- C. Distributive shock
- D. Obstructive shock

- The heart fails to pump blood out:

- A. Hypovolemic shock
- B. Cardiogenic shock
- C. Distributive shock
- D. Obstructive shock