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Pathyophysiology and Classification of Shock. KENNEY WEINMEISTER M.D. Definition. Shock is a physiologic state characterized by a significant, systemic reduction in tissue perfusion, thereby resulting in decreased tissue oxygen delivery. Stages of Shock. Early, Preshock, Warm shock

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definition
Definition
  • Shock is a physiologic state characterized by a significant, systemic reduction in tissue perfusion, thereby resulting in decreased tissue oxygen delivery.
stages of shock
Stages of Shock
  • Early, Preshock, Warm shock
  • Compensation by body’s homeostatic mechanisms
    • Tachycardia, Peripheral vasodilatation and modest decrement in systemic BP
stages of shock4
Stages of Shock
  • Shock
  • Homeostatic mechanisms are overwhelmed
  • Signs and symptoms of organ dysfunction
    • Tachycardia, tachypnea, metabolic acidosis, oliguria, and cool and clammy skin
    • 20 to 25% fall in effective blood volume
    • Fall in CI to < 2.5L/min/M2
    • Activation of mediators of sepsis
stages of shock5
Stages of Shock
  • End Organ Dysfunction
  • Pathophysiology
    • AG II & NE cause increased Ca+2 in cytosol
    • Ca + calmodulin = P+myosin
    • P+myosin + actin = Myosin ATPase
    • Myosin ATPase = muscle contraction
pathophysiology of end organ shock
Pathophysiology of End Organ Shock
  • Activation of ATP sensitive potassium channels
    • Activation causes hyperpolarization
    • Closure of Ca channels
    • Activated by decrease in cellular ATP and increases in cellular H+ and lactate
    • Natriuretic peptide and nitric oxide
pathophysiology of end organ shock7
Pathophysiology of End Organ Shock
  • Increased production on Nitric Oxide
    • activation of myosin light-chain phosphatase
    • leads to dephosphoralation of myosin
  • Vasopressin deficiency
    • potentiates vasoconstrictor effects of NE
    • directly inactivates Katp channels
    • blunts increase in cGMP
    • decreases synthesis of NO synthase
pathophysiology of end organ shock8
Pathophysiology of End Organ Shock
  • Vascular smooth muscle tone is lost
  • Resistant vasodilatation
  • End organ dysfunction and death
classification of shock
Classification of Shock
  • Hypovolemic shock
  • Cardiogenic shock
  • Distributive shock
hypovolemic shock
Hypovolemic Shock
  • Results from decreased preload
  • Hemorrhagic
    • Trauma, GIB, Ruptured aneurysm
  • Volume loss
    • Third spacing, GI losses, burns, insensible losses
cardiogenic shock
Cardiogenic Shock
  • Pump failure
  • Cardiomyopathies
    • Ischemic right and left ventricle,
    • Dilated
    • Stunned myocardium
cardiogenic shock continued
Cardiogenic Shock continued
  • Arrhythmia's
    • Bradyarrhythmias
    • Tachyarrhythmias
  • Mechanical
    • Valvular; MR, AI, AS
    • VSD
    • Atrial myxoma
cardiogenic shock continued13
Cardiogenic Shock continued
  • Obstructive
    • Massive PE
    • Tension pneumothorax
    • Constrictive pericarditis
    • Tamponade
    • Severe pulmonary hypertension
distributive shock
Distributive Shock
  • Vasodilatory shock resulting in severe decrease in SVR
    • Septic shock
    • Activation of systemic inflammatory response
    • Toxic shock syndrome
    • Anaphylaxis
    • Drug or toxins
distributive shock continued
Distributive Shock continued
  • Addisonian crisis
  • Myxedema coma
  • Neurogenic shock
evaluation
Evaluation
  • H & P
  • Labs
  • CXR
  • EKG
treatment
Treatment
  • Goal is early intervention to prevent irreversible organ damage
    • Recognize early shock
    • Diagnose and correct the underlying cause
  • Early goal directed therapy in sepsis
    • In hospital mortality 46.5% vs 30.5% for treatment group
    • NEJM, vol 345,No 19 Nov 8 2001
treatment18
Treatment
  • Fluid resuscitation
    • CVP 8-12
  • Vasopressors
    • Norepinephrin infuse mcg/min (4mcg/min)
    • Dopamine infuse mcg/kg/min
    • Epinephrine infuse mcg/min (range 1-10 mcg)
    • Vasopressin infuse units/min (range 0.01 to 0.1 units/minute)