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SHOCK CAUSES AND MANAGEMENT DEFINITION Condition in which arterial blood flow/perfusion (Blood Pressure) is inadequate to meet tissue metabolic needs(maintain normal funtion of vital organs) In a healthy adult : Hypotension – arterial BP<90mmHg Shock – arterial BP <60mmHg

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shock

SHOCK

CAUSES AND MANAGEMENT

definition
DEFINITION

Condition in which arterial blood flow/perfusion (Blood Pressure) is inadequate to meet tissue metabolic needs(maintain normal funtion of vital organs)

In a healthy adult :

Hypotension – arterial BP<90mmHg

Shock – arterial BP <60mmHg

Postural Hypotension- Drop in Systolic BP of 10-20mmHg or increase in Pulse rate of >15 with position change indicates hypovolemia

differential diagnosis of shock
DIFFERENTIAL DIAGNOSIS OF SHOCK
  • HYPOVOLEMIA
  • CARDIAC PUMP FAILURE
  • OBSTRUCTIVE
  • DISTRUBUTIVE - SYSTEMIC VASODILATATION

GET HISTORY FROM RELATIVES

symptoms signs of hypovolemia blood loss
SYMPTOMS & SIGNS OF HYPOVOLEMIA – Blood Loss

in a 70kg patient circulating blood volume is 5 liters

(approx 70 ml/kg)

Loss of Blood

15% (700-750 ml)- may produce little or no obvious symptoms

30% (1500ml) –mild tachycardia, tachpnoea and anxiety

30-40%-(1750ml) tachycardia (110-120beats per min) & marked hypotension

40% (2000ml) is life threatening

Plasma-5%body wt=3,500 ml

Interstitial Fluid- 15% body wt = 10,500ml

Intracellular volume= 40% body wt= 28,000ml

hypovolemia from diarrhoea vomiting loss of water lytes
Hypovolemia from Diarrhoea/Vomiting- loss of water & lytes
  • Thirsty
  • Passes small amounts yellow urine
  • Dizzy on sitting (postural hypotension – 5% body wt loss =3500 ml Shock – 10% = 7000ml
  • Dry axilla & groin ( 1500ml water deficit)
  • Decreased tissue turgor- tongue has furrows,skin folds on pinching it , sunken eyeballs
  • Cool clammy extremities
  • Tachycardia
  • Weak or absent pulses
  • Empty neck veins in the supine position
cardiogenic cardiac pump failure
Cardiogenic –Cardiac Pump Failure

Myocardial Infarction

Cardiomyopathy

Dysrhythmia

    Tachyarrhythmia

    Bradyarrhythmia

Acute valvular dysfunction (especially regurgitant lesions)

Rupture of ventricular septum or free ventricular wall

signs symptoms ofshock produced by pump falure heart failure
SIGNS & SYMPTOMS OFSHOCK PRODUCED BY PUMP FALURE HEART FAILURE
  • Sudden onset in VT/VFib
  • Chest pain in MI
  • Absent heart sounds or severe tachycardia
  • Raised JVP
  • Pedal oedema
  • Basal lung rales
  • Hepatojugular reflux
obstructive shock decrease in cardiac filling
Obstructive shock -Decrease in Cardiac Filling

Tension pneumothorax

Disease of pulmonary vasculature (massive pulmonary emboli, pulmonary hypertension)

  Pericardial disease (tamponade, constriction)

  Cardiac tumor (atrial myxoma)

  Left atrial mural thrombus

  Obstructive valvular disease (aortic or mitral stenosis)

symptoms of obstructive shock
SYMPTOMS OF OBSTRUCTIVE SHOCK

Raised JVP-

  • Tension pneumothorax- absent breath sounds
  • Cardiac tamponade- distant heart sounds
  • Cardiogenic shock
  • Pulmonary embolism- chest pain, dyspnoea,hemoptysis,swollen calf, h/o immobilisation
  • Fluid overload
distributive shock decrease in systemic vascular resistance vasodilatation
Distributive shockDecrease in Systemic Vascular Resistance - Vasodilatation

Septic shock

  Anaphylactic shock,

  Neurogenic shock

  Acute adrenal insufficiency

Vasodilator drugs

signs symptoms of septic shock
Signs & Symptoms of Septic Shock

Usually gram-bacteria (E.coli,Kleb,Pseuo,Prot.)

Fever with chills,

confusion,

hyperglycemia

in old/babies, diabetes, immunosuppressed,

H/o recent surgery/manipuation of urinary,biliary,gynae system

s s anaphylaxis
S&S ANAPHYLAXIS

History of

  • Atopy
  • Insect bite esp wasp/bees
  • Food (peanuts, fish, eggs, seafood),
  • Drugs (penicillin, blood products, iron inj, aspirin, NSAIDS, vaccines

Urticaria,

Oedema of skin and mucous membranes (angioedema),

Wheezing- bronchospasm

Stridor- laryngeal oedema

Generalised itching, rhinitis, conjuntival redness

neurogenic shock
Neurogenic Shock

Causes–

spinal cord injury,

spinal anaesthesia,

vasovagal- pain/fright-h/ofainting,bradycardia,

assessment of shock patient
ASSESSMENT OF SHOCK PATIENT

Pt in Cardiac Arrest- call for help

Moniter-

V fib –shock

V tach- vagal manoeuvers- carotid sinus massage

Adenosine-6mg iv fast followed by 5 ml saline flush Rpt in 1-2 min 12mg

Flat line- CPR

assessment of shock patient17
ASSESSMENT OF SHOCK PATIENT

Check airway- clear of blood/vomitus

Start O2 or intubate if unconscious

Auscultate lungs for air entry

absent- tension pneumothorax / hemothorax? (percussion)

rales – cardiac failure?

rhonchi- anapyhlaxis? LVFailure

Auscultate heart-

distant sounds- cardiac tamponade?

Murmurs- acute valve problems?

JVP

flat- hypovolemia

distended- cardiac failure?, PE,,Ten PT,,Cardiav Tamp?

Abdomen-

Fullness or pulsatile mass( ruptured aneurysm?)

Tender – pancreatitis, perforation?

assessment of shock patient18
ASSESSMENT OF SHOCK PATIENT

BP on both arms- different –dissection of aorta

Fever- sepsis

Pt cold clammy- hypovolemia? Cardiac failure?

Hypovolemia signs- skin/tongue turgor, sunken eyeballs,pallor

Pedal oedema- cardiac failure

Blood around mouth, malena? ( do PR)

Urticaria, wheals, soft tissue swelling (anaphylaxis)

assessment of shock patient19
ASSESSMENT OF SHOCK PATIENT

Investigations

ABG

ECG

CXR

Blood tests-Hb,WBC,platelets, Lytes,Blood sugar Creatinine,LFT, PT,PTT,Grouping & xmatch

Cultures- Blood,urine,sputum

ECHO

Ultrasound abd , CT head

treatment hypovolemia diarrhoea vomiting
TREATMENT- HYPOVOLEMIADiarrhoea. Vomiting

Insert 2 IV canulae (16 guage)-forearm, groin, central line

Cut down

Head down position

Infuse normal saline or ringers lactate- replace ½ the loss

Insert Urinary catheter(Foley)- 1ml/kg

Keep assesssing – dec IV when BP >90 and pt urinating

treatment of heart failure
TREATMENT OF Heart Failure

Myocardial Infarction

MONA

Dopamine

treatment of pneumothorax
Treatment of Pneumothorax

Insert chest tube in 2nd intercostal space in midclavicular line

Heimlich valve

treatment of sepsis
Treatment of Sepsis

Antibiotics

Correct cause of sepsis

IV Fluids-leaky capillaries

treatment of anaphylaxis
Treatment of Anaphylaxis

Airway-

O2 mask/ intubate, / cricothyroidotomy with 14 guage canula or small ET tube

Head down

IV line

Adrenaline 0.5 ml of 1:1000 soln IM

or 5ml of 1:10,000 soln IV(0.1ml /kg body wt in children) slowly at 1ml/min till Bp recorded

rpt every 10min acc to BP/pulse

Hydrocortisone- 100-300mg IV

H1 blocker-

antihistamine- promethazine 25-50mg IV Rpt 4-6hrly

Aminophylline IV for bronchospasm (250mg IV)

dopamine
DOPAMINE

Acts on diff receptors at diff doses

Low dose- ( 0.5-2 microgm/kg/min) D1 on vascular smooth muscle causes vasodilatation of renal, mesenteric, cerebral, coronary vascular bed

Mod dose (2-5 microgm/kg/min) Beta1 receptors- positive ionotropic and chronotropic

High dose - > 5 microgm/kg/min) Alpha receptors- vasoconstiction and decrease blood flow

hemodynamic calculations
Hemodynamic calculations

CVP- = R atrial pressure = 1-7 mm Hg

Pulm art pressure 15-30/3-12 mmHg

PAWP= Pulm artery wedge pressure=3-12 mm Hg

Cardiac index = cardiac output 4-6 l/min

Body surface area

=2.8-3.6l/min/sq.m

( sp gr of Hg=13.7)