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Shock Dr.Hadeel AlOtair ABIM,MRCP,FCCP

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Shock Dr.Hadeel AlOtair ABIM,MRCP,FCCP. Outline. Definition & mechanism of shock. Consequences of Shock. How to diagnose shock? Classification of Shock. Causes of various types of shock Basic principles in management of shock. Shock. - PowerPoint PPT Presentation

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Page 1: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP
Page 2: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Outline

Definition & mechanism of shock.Consequences of Shock.How to diagnose shock? Classification of Shock.Causes of various types of shockBasic principles in management of shock.

Page 3: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Shock

Reduction of effective tissue perfusion leading to cellular and circulatory dysfunction

Page 4: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Shock

The Aim of perfusion is to achieve adequate Cellular OxygenationThis requires :

Red Cell OxygenationRed Cell Delivery To Tissues

Fick Principle

Page 5: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Fick Principle

Air’s gotta go in and out.Blood’s gotta go round and round.Any variation of the above is not a

good thing!

Page 6: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP
Page 7: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Shock

Red Cell Oxygenation

Oxygen delivery to alveoli

Adequate FiO2

Patent airwaysAdequate ventilation

Page 8: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Shock

Red Cell Oxygenation

Oxygen exchange with blood

Adequate oxygen diffusion into bloodAdequate RBC mass/Hgb levelsAdequate RBC capacity to bind O2

– pH– Temperature

Page 9: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Shock

Red Cell Delivery To Tissues

Adequate perfusionBlood volumeCardiac output

– Heart rate– Stroke volume (pre-load, contractility, after-load)

Conductance– Arterial resistance– Venous capacitance

Page 10: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP
Page 11: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

ShockRed Cell Delivery To Tissues

Adequate RBC mass

Adequate Hgb levels

Adequate RBC capacity to unbind O2

pHTemperature

Page 12: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Consequencies of Shock

Inadequate oxygenation or perfusion causes:

Inadequate cellular oxygenationShift from aerobic to anaerobic

metabolism

Page 13: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

ANAEROBIC METABOLISM

GLUCOSE METABOLISM

2 LACTIC ACID

2 ATP

HEAT (32 kcal)

Glycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid

Page 14: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

AEROBIC METABOLISM

6 O2

GLUCOSE

METABOLISM

6 CO2

6 H2O

36 ATP

HEAT (417 kcal)

Glycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid

Oxidative phosphorylation: Each pyruvic acid is converted into 34 ATP

Page 15: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Anaerobic Metabolism

Occurs without oxygenoxidative phosphorylation can’t occur without oxygenglycolysis can occur without oxygencellular death leads to tissue and organ deathcan occur even after return of perfusion

organ dysfunction or death

Page 16: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

InadequateCellularOxygenDelivery

AnaerobicMetabolism

InadequateEnergyProduction

MetabolicFailure

LacticAcidProduction

MetabolicAcidosisCELL

DEATH

Ultimate Effects of Anaerobic Metabolism

Page 17: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Shock

Markers Of Hypoperfusion

↑S.LactatePerfusion related acidemiaHypotension

Page 18: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Maintaining perfusion requires:

VolumePumpVessels

Failure of one or more of these causes shock

Page 19: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Shock SyndromesHypovolemic Shockblood VOLUME problem

Cardiogenic Shock Blood pump problem

ObstructiveShock Filling Problem

Distributive Shock blood VESSEL problem

Page 20: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Hypovolemic Shock( Loss of Volume)

blood loss Trauma:BLOOD YOU SEE BLOOD YOU DON’T SEE

Non-traumaticVaginalGIGU

Fluid loss (Dehydration)

–Burns_Diarrhea–Vomiting–Diuresis–Sweating

–Third space lossesPancreatitisPeritonitisBowel obstruction

Page 21: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Signs

Due to Hypoperfusion– Altered mental state– Impaired capillary filling– ↓Urine output– Skin temperature cold clammy– BP(narrow pulse pressure, Postural↓BP)– Low volume pulse– Skin colour:peripheral cyanosis

Compensatory responses _ Tachycardia, _ pallor

Page 22: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Key Issues In Shock

Recognize & Treat during compensatory phase

Best indicator of resuscitation

effectiveness = Level of Consciousness

Restlessness, anxiety, combativeness = Earliest

signs of shock

Page 23: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Hypovolemic Shock managementgoal: Restore circulating volume, tissue perfusion & correct cause

• Airway & Breathing• Control bleeding• Elevate lower extremities • Avoid Trendelenburg

Page 24: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Two large bore IV lines/central lineFluids / Blood & Products /vasopressors

Target arterial BP – SBP ≥ 90 mmHg - MAP ≥65 mmHg.

Bladder catheterArterial Cannulation

Page 25: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Key Issues In Shock

Tissue ischemic sensitivityHeart, brain, lung: 4 to 6 minutesGI tract, liver, kidney: 45 to 60 minutesMuscle, skin: 2 to 3 hours

Resuscitate Critical Tissues

First!

Page 26: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Consequence Of Volume Loss:

15%[750ml]- compensatory mechanism maintains cardiac output

15-30% [750-1500ml]-, decreased BP & urine output

30-40% [1500-2000ml] -Impaired compensation & profound shock along with severe acidosis

40-50% - refractory stage

Page 27: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Shock

Cardiogenic Shock = Pump Failure

MyopathicM ICHFCardiomyopathy

ArrhythmicTachy or bradyarrhythmias

–Mechanical Valvular Failure

HOCM

Page 28: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Cardiogenic Shock

History : Chest pain, Palpitations,SOB RHD,IHD

Physical exam:Signs of ventricular failureHeart:Murmurs,S3,S4

Page 29: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Cardiogenic Shock

Supine, or head and shoulders slightly elevated, do NOT elevate lower extremities

Treat the underlying cause if possible examples

Page 30: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Treat rate, then rhythm, then BP

Correct bradycardia or tachycardia Correct irregular rhythms Treat BP

↑Cardiac contractility(inotropes)– Dobutamine, Dopamine

Page 31: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Distributive Shock

Inadequate perfusion of tissues due to mal-distribution of blood flow

(blood vessels problem)Cardiac pump & blood volume are normal but blood is not reaching the tissues

Page 32: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Distributive Shock Septic Shock

Anaphylactic Shock Histamine is released

– Blood vessels» Dilate (loss of resistance)» Leak (loss of volume)

– Extravascular smooth muscle spasm» Laryngospasm» Bronchospasm

Neurogenic/Vasogenic(spinal cord)

Endocrinologic

Page 33: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Sepsis & Septic shock

Page 34: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Septic Shock management

A B C,Assist ventilation & Augment OxygenationMonitor Tissue perfusion-

Restore Tissue perfusion-

IVFluids, VasopressorsIdentification & Eradication of septic fociSpecific Therapies

-

Page 35: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Neurogenic Shock

Patient supine; lower extremities elevatedAvoid Trendelenburg Infuse isotonic crystalloid Maintain body temperature

Page 36: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Anaphylactic Shock

Suppress inflammatory responseAntihistaminesCorticosteroids

Oppose histamine responseEpinephrine

– bronchospasm & vasodilation

Replace intravascular fluidIsotonic fluid titrated to BP ~ 90 mm

Page 37: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Obstructive shock

Impaired diastolic fillingCardiac tamponadeConstrictive pericarditisTension pneumothorax

Increased ventricular afterload Pulmonary embolism

Page 38: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Obstructive Shock

Treat the underlying causeTension PneumothoraxPericardial Tamponadeanticoagulation

Isotonic fluids titrated to BP w/o pulmonary edemaControl airway

Intubation

Page 39: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Key Issues In Shock

Falling BP = LATE sign of shockBP is NOT same thing as perfusionPallor, tachycardia, slow capillary refill = hypoperfusion, until proven otherwise

Page 40: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Shock Management

Avoid vasopressors until hypovolemia ruled out, or

correctedSqueezing partially

empty tank can cause ischemia, necrosis of

kidney and bowel

Page 41: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP
Page 42: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Hypovolemic Shock:

Fluid loss: Dehydration Nausea & vomiting, diarrhea, massive diuresis, extensive burns

Blood loss: trauma: blunt and penetrating BLOOD YOU SEE BLOOD YOU DON’T SEE

Page 43: Shock Dr.Hadeel AlOtair  ABIM,MRCP,FCCP

Initial Management Hypovolemic Shock

goal: Restore circulating volume, tissue perfusion & correct cause

• Arrest ongoing blood loss

• Early Recognition- Do not relay on BP! (30% fld loss)• Restore circulating volume - IV fluids 1-2 ltr-Crystalloid VS Colloids - Blood & Products