1. shock Lt. col. Dr. Zaman Ranjha Associate prof. of Surgery

2. ShockObjectives • To understand the structured approach to cerculatory problems • To recognize and manage shock

3. Shock • Inadequate organ perfusion and tissue oxygenation • Most often due to hypovolaemia in surgery and trauma

4. ShockAssessment Blood pressure Heart rate Capillary refill Peripheral temperature Peripheral colour Urine output

5. Types of Shock • Hypovolaemic • Cardiogenic • Obstructive • Neurogenic • Endocrine • Anaphylactic • septic

6. Severity of shock • Compensated Vasomotor response At the cost of skin, muscles and GIT. Acidosis beyond 12 Hrs- MOD • Decompensated 30-40% volume loss Cadiopulmonary and renal compensation is knocked out

7. ShockPathophysiology • Cellular Autodigestive enzyme-cell lysis • Microvascular o2 free radical- endothelial damage • Mode of death rapid-cadiopulmonary delayed-organ ischemia/reperfusion

8. Hypovolumic shock • Fluid loss less intake, increased loss- vomiting, GIT, Renal third space- pancreatitis Blood loss

9. ShockSites of blood loss Closed Femoral # 1.5-2 litres Closed Tibial # 500 ml Pelvic # 3 litres Rib # (each) 150 ml Haemothorax 2 litres Hand sized wound 500 ml Fist sized clot 500 ml

10. ShockConcealed blood loss • Abdominal Cavity • Pleural Cavity • Femoral Shaft • Pelvic Fractures • Scalp (children)

11. Types Of Bleeding • Compressible - usually peripheral • Non-compressible - e.g. intra-abdominal - Surgery required

12. Shocksystemic effects • CVS.-Sympathomymatic tachycardia-vasoconstriction Resp. -compensatory respiratory alkalosis Renal. Reduced perfusion, GFR, Urine Na , H2o , conservation Endocrine.Adrenal,cortisone =Na +water catecholamine Hypothalamus- vasopressin

13. ShockClinical Signs • Altered mental state : anxiety to coma • Pulse present ? - radial systolic > 80 mmHg - femoral systolic >70 mmHg - carotid systolic > 60 mmHg • Tachycardia • Pulse pressure narrowed

14. ShockClinical Signs • Skin - cold, pale, sweaty, cyanosed • Capillary refill time > 2 seconds • Blood pressure • JVP • Urine output < 0.5 ml/kg/hr • Respiratory rate

15. Clinical Signs In Shock

16. Blood Loss < 750ml

17. Blood Loss 750-1500ml

18. Blood Loss >1500ml

19. Cardiogenic Shock • myocardial contusion • cardiac tamponade • tension pneumothorax • penetrating wound of heart • myocardial infarction • Valvular heart disease • arrhythmya

20. ShockObstructive shock • Cardiac temponade • Tension pneumothorax • Pulmonary embolism Reduced preload Reduced cardiac out put Engorged neck veins + oedma

21. ShockEndocrine shock • May be combination of three • Adrenal- hypovolumic • Hypothyroid- neurogenic • Hyperthyroid – high out put

22. ShockDistributive shock No volume depletion 1-Septic shock Endotoxin-vasodilation-AV shunting-cellular hypoxia 2- Anaphylactic shock Histamine- vasidilatation 3- Neurogenic- vasomotor

23. Shock ?

24. Shock Management • A + B, oxygen (if available) • Two large bore intra-venous cannulae • Stop obvious bleeding • Fluid replacement • Maintain temperature • Analgesia

25. ShockStop bleeding • Chest • Drain tube and re-expand lung • Emergency thoracotomy rarely • Abdomen • Laparotomy if hypotensive after fluids • Limbs • Pressure dressing • Tourniquet is last resort

26. ShockFluid replacement • Warm fluids if possible • Colloids or crystalloids? • Consider hypotensive resuscitation if haemostasis not secure- parallel with surgery • Consider oral resuscitation • Resuscitation beneficial –dehydration

27. ShockFluid replacement - How much? 1000-2000ml 0.9% Saline or Ringer’s Reassess 1000-2000ml 0.9% Saline or Ringer’s Reassess Consider blood Consider surgery Aim for systolic BP>90 + HR <100

28. Shock Consider blood Tx • Haemodynamic instability in spite of fluids • Haemoglobin <7g/dl and patient still bleeding

29. Shock ?

30. ShockSummary • Careful assessment • Stop the bleeding • Replace volume • Correct the cause