1. DEFINITION SHOCK IS A CIRCULATORY SYSTEM ABNORMALITY THAT RESULTS IN INADEQUATE OXYGEN PERFUSION AND TISSUE OXYGENATION

2. PHYSIOLOGICAL EXHAUSTION-THE TRIAD OF DEATH HYPOTHERMIA ACIDOSISCOAGULOPATHY 3. HYPOPERFUSION STATE RESULTS IN CELLULAR ANAEROBIC METABOLISM AND LACTIC ACIDOSIS.ACIDOSIS LEADS TO DECREASED FUNCTION OF COAGULATION PROTEASES-LEADS TO COAGULOPATHY AND FURTHER HAEMORRHAGE. 4. UNDERPERFUSED MUSCLE IS UNABLE TO GENERATE HEAT AND HYPOTHERMIA OCCURS.COAGULATION FUNCTIONS POORLY AT LOW TEMPERATURE AND THERE IS FURHER HAEMORRHAGE,HYPOPERFUSION AND HYPOTHERMIA.THESE 3 FACTORS RESULT IN A DOWNWARD SPIRAL LEADIING TO PHYSIOLOGICAL EXHAUSTION AND DEATH 5. 1.HYPOVOLEMIC-HAEMORRHAGIC NON-HAEMORRHAGIC 2.CARDIOGENIC SHOCK 3.OBSTRUCTIVE 3.DISTRIBUTIVE SHOCK-ANAPHYLACTIC SEPTIC 4.ENDOCRINE SHOCK 6. STAGES OF SHOCK COMPENSATED-- HR, Vasoconstriction, CO, normal BP DECOMPENSATED--, HR, hypothermia, blood pressure, prolonged capillary refill time, poor peripheral pulses, and eventually urine output. IRREVERSIBLE SHOCK 7. BLEEDING-TRAUMA,GI BLEED,RUPTURED ANEURYSM PROTRACTED VOMITING OR DIARRHEA ADRENAL INSUFFICIENCY THIRD SPACING-INTESTINAL OBSTRUCTION,PANCREATITIS 8. HAEMORRHAGIC SHOCK-COMMONEST CAUSE OF SHOCK IN TRAUMA PATIENTS NON-HAEMORRHAGIC CAUSES CARDIAC PUMP PROBLEMS-CARDIAC TAMPONADE,TENSION PNEUMOTHORAX,MYOCARDIAL CONTUSION NEUROGENIC SHOCK SEPTIC SHOCK 9. HAEMORRHAGIC SHOCK HAEMORRHAGE MAY BE REVEALED OR CONCEALED. HAEMORRHAGE EXSANGUINATION FROM OPEN ARTERIAL WOUND OR FROM HAEMETEMESIS FROM A DUODENAL ULCER CONCEALED HAEMORRHAGE IS CONTAINED WITHIN THE BODY CAVITY.EG-WITHIN CHEST,ABDOMEN,PELVIS WITH CONTAINED VASCULAR INJURY 10. PRIMARY,SECONDARY AND REACTIONARY HAEMORRHAGE PRIMARY HAEMORRHAGE IS HAEMORRHAGE OCCURING IMMEDIATELY AS A RESULT OF INJURY REACTIONARY HAEMORRHAGE (WITHIN 24 HOURS) CAUSED BY DISLOGEMENT OF CLOT BY RESUSCITATION,NORMALISATION OF BP AND VASODILATATION SECONDARY HAEMORRHAGE IS CAUSED BY SLOUGHING OF VESSEL WALL .IT USUALLY OCCURS AFTER 7-14 DAYS AFTER INJURY BY FACTORS SUCH AS INFECTION,PRESSURE NECROSIS(DRAIN)OR MALIGNANCY 11. BLOOD LOSS IN SITE FRACTURE TIBIA/HUMERUS-750 ML BLOOD FRACTURE FEMUR-1500 ML BLOOD FRACTURE PELVIS-2 TO 3 LITRES OBLIGATORY EDEMA IN SOFT TISSUES 12. SBP90/mt Tachypnea Oliguria Metabolic acidemia Hypoxemia Cutaneous vasoconstriction Mental changes-anxiety,agitation,lethargy 13. APPROPRIATE HISTORY AND CLINICAL EXAMINATION ADJUNCTS FOR CONFIRMATION CVP CHEST/PELVIC XRAY ULTRASOUND 14. MINIMUM REQUIREMENTS MONITOR SBP,URINE OUTPUT,BP,HR,MENTAL STATE ADDITIONAL MODALITIES CVP INVASIVE BP MONITORING CARDIAC OUTPUT BASE DEFICIT SERUM LACTATE 15. CLASSIFICATION OF DEGREE OF HAEMORRHAGE 16. INITIAL MANAGEMENT OF HAEMORRHAGIC SHOCK DIAGNOSIS AND TREATMENT IS DONE SIMULTANEOUSLY 2 BASIC PRINCIPLES ARE STOP BLEEDING REPLACE THE VOLUME ANY SHOCK SHOULD BE ASSUMED HYPOVOLEMIC UNTIL PROVED OTHERWISE AND HYPOVOLEMIA SHOULD BE ASSUMED TO BE DUE TO HAEMORRHAGE UNTIL THIS HAS BEEN EXCLUDED 17. INITIAL MANAGEMENT OF HAEMORRHAGIC SHOCK ASSESS ABCDE BASELINE RECORDINGS-BP,PR,URINE OUTPUT,LEVEL OF CONSCIOUSNESS CONTROL OBVIOUS HAEMORRHAGE.DIRECT PRESSURE SHOULD BE PLACED OVER SITE OF EXTERNAL HAEMORRHAGE ADEQUATE IV ACCESS-2 LARGE BORE IV CANNULA(MINIMUM 16 GUAGE) IF PERIPHERAL LINE NOT POSSIBLE-CENTRAL LINE,VENOUS CUT DOWN.BLOOD DRAWN FOR CROSS MATCHING ASSESS TISSUE PERFUSION 18. INITIAL FLUID THERAPY RINGER LACTATE IS THE FIRST CHOICE,2ND IS NORMAL SALINE AN INTIAL BOLUS IS GIVEN AS RAPIDLY AS POSSIBLE.DOSE OF 1 -2 LITRES FOR ADULTS 20 ML/KG FOR CHILDREN. 19. DYNAMIC FLUID RESPONSE PATIENTS CAN BE DIVIDED INTO RAPID RESPONDERS,TRANSIENT RESPONDERS AND NON RESPONDERS BASED ON RESPONSE TO FLUID THERAPY 20. RESPONSES TO INITIAL FLUID RESUSCITATIONRAPID RESPONS E TRANSIENT RESPONSE NO RESPONSE VITAL SIGNS RETURN TO NORMAL TRANSIENT IMPROVEM ENT ABNORMAL ESTIMATED BLOOD LOSS MINIMAL (10 20 %) MODERATE AND ONGOING (20 40 %) SEVERE (>40%) NEED FOR MORE CRYSTALLOID LOW MODERATE IMMEDIATE NEED FOR POSSIBLY LIKELY HIGHLY LIKELY 21. EXCESSIVE BLOOD LOSS FROM FRACTURED BONE MAY BE PREVENTED BY AVOIDING MOVING THE PATIENT FROM ONE COUCH TO ANOTHER. .FOR FRACTURES OF PELVIS,TEMPORARY STABILISATION WITH AN EXTERNAL FIXATOR HAS BEEN FOUND TO BE USEFUL IN REDUCING HAEMORRHAGE 22. I.V. Solutions Crystalloid Colloid Whole Blood or Blood Products Water and Glucose 23. Crystalloids (Isotonic) Solutions of ions with an osmolarity similar to that of plasma. Effective, short term, volume replacement Do NOT have O2 carrying capacity Do NOT contain protein 24. Crystalloids (Isotonic) Most common crystalloids Normal saline Fluid of choice in combat Ringers lactate Most physiologically adaptable solution available Hartmann,s solution 25. Crystalloids (Isotonic) Precautions Always consider fluid volume overload Excessive infusion of electrolytes may cause electrolyte imbalances DO NOT use in patients with Cardiac failure Liver disease 0.9% NaCl is C/I in metabolic axidosis as it is an acidifying solution, which may slow down the resolution of the metabolic acidosis, so in that case use RL 26. C OLLOIDS are large molecules that cannot freely diffuse through the capillary membrane NO oxygen carrying capacity ALBUMIN HETASTARCH SYNTHETIC The advantage of colloids is that since they do not rapidly diffuse across the capillary membrane, they act to hold water in the intravascular space and maintain intravascular volume expansion for longer periods of time than crystalloids 27. Water and Glucose These solutions are Hypotonic Most common concentrations: D5W Fluid replacement and caloric supplementation D50W treats hypoglycemic (low blood sugar) in adults 28. Water and Glucose Contraindications: DO NOT use in HEAD INJURIES Will cause cellular swelling Precautions: Volume overload Electrolyte imbalance 29. Whole Blood Ideal replacement fluid if blood is being lost Indications Acute massive blood loss Will resolve symptoms of hypovolemic shock and anemia 30. VASSOPRESSOR AND IONOTROPICS NOT AS FIRST LINE THERAPY Administration of this agents in absence of adequqte preload lead to decrease coronary perfusion and depletion of myocardial oxygen reserve Noradrenaline distributive shock Ionotrops in - cardiogenic shock 31. SEPTIC SHOCK Severe sepsis with cardiovascular organ dysfunction, i.e. hypotension (systolic blood pressure [SBP] < 5th centile non-specific systemic inflammatory response to infection,trauma, burns, surgery etc. Characterized by abnormalities in 2 or more of the following body temperature heart rate respiratory function peripheral leucocyte count 32. SEPTIC SHOCK --management RESUSCITATION ABC FLUID THERAPY-- aggressive fluid resuscitation with crystalloids or colloids at 20 mls/kg as rapid IVpush over 5-10 mins. Can be repeated up to 60 mls/kg or more. - correct hypoglycaemia and hypocalcaemia IONOTROPES -- IV Dopamine 5 - 15 g/kg min IV Dobutamine 5 - 15 g/kg/min - for fluid refractory and dopamine/dobutamine refractory shock Adrenaline is given 33. ANTIMICROBIAL-- IV antibiotics should be administered immediately after appropriate cultures are taken. Start empirical, broad spectrum to cover all likely pathogens antibiotic regime to be modified accordingly once C&S results 34. RESPIRATORY SUPPORT- use PEEP and FIO2 to keep SaO2 > 90%, PaO2 > 80 mmHg SUPPORTIVE THERAPY- packed cells transfusion if Hb