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SHOCK, FLUIDS AND ELECTROLYTE THERAPY SHOCK\

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SHOCK, FLUIDS AND ELECTROLYTE THERAPY SHOCK\ A variety of disorders in which there is a failure of oxygen supply to the tissue (inadequate peripheral tissue perfusion). – PowerPoint PPT presentation

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Title: SHOCK, FLUIDS AND ELECTROLYTE THERAPY SHOCK\


1
SHOCK, FLUIDS AND ELECTROLYTE THERAPYSHOCK\
  • A variety of disorders in which there is a
    failure of oxygen supply to the tissue
    (inadequate peripheral tissue perfusion).
  • The underlying pathology in shock, what ever the
    cause, is tissue hypoxia with release of toxic
    metabolites.
  • Hypoxia stimulates the secretion of hormones
    (adrenaline, noradrenaline, dopamine, glucagon
    and glucocorticoids).
  • Prolonged hypoxia damages the endothelial cells
    lining the arterioles and capillaries of the
    microcirculation, leading to leakage of fluid out
    of the intravascular compartment in to the
    interstitial spaces (early in septic shock).

2
TYPES OF SHOCK
  • HYPOVOLAEMIC SHOCK Loss of circulating volume
    from haemorrhage, vomiting, diarrhoea, loss of
    plasma as in burns, heat stroke, acute abdomen, N
    G tubes and other drains and fistulae.
  • SIGNS OF HYPOVOLAEMIC SHOCK
  • Tachycardia
  • Cold and clammy peripheries
  • Droplets of sweat on the face and hands
  • Restlessness, anxiety and confusion
  • Hypotension
  • Tachycardia
  • oliguria

3
CLASSES OF HAEMORRHAGIC SHOCK
  • The percentage of blood loss in each class is the
    same as the score in the tennis game15 30 40
  • Class I up to 15
  • Class II 15 30
  • Class III 30 40
  • Class IV over 40
  • Hypotension first occurs in class III shock.

4
  • CARDIOGENIC SHOCK The heart or pump failure
    heart failure, dysrrhythmias, trauma to the
    heart, pulmonary embolism, tension pneumothorax,
    cardiac tamponade.

5
SEPTIC AND ANAPHYLACTIC SHOCK
  • Toxins from damaged tissue react with blood
    vessels which then leak fluid in to tissues.
    This results in abnormalities of the peripheral
    vasculative
  • SIGNS OF SEPTIC / ANAPHYLAXIC SHOCK
  • Early in septic shock, there may be an increased
    flow of blood throughout the peripheral
    circulation owing to opening of the pre-capillary
    sphincter warm phase.
  • Short lived and is followed by vasoconstriction
    so that the patient becomes cold clammy.
  • Many patients are first seen after they have been
    in shock for some time.
  • Urticarial rash
  • Bronchospasm
  • Oedema of the face

6
NEUROGENIC SHOCK
  • Loss of the sympathetic tone with a typical
    presentation of hypotension. It should be
    treated for hypovolaemia. Emotional disturbance
    may lead to neurogenic shock.

7
  • Irreversible shock refers to advanced stage when
    cellular hypoxia is so severe that death is
    inevitable. Shock is essentially a clinical
    diagnosis. Any of the above types of shock can
    progress to irreversible shock if treatment is
    delayed.
  • Investigations help more with monitoring
    treatment than diagnosis.

8
TREATMENT OF SHOCK
  • The goal is to restore oxygen delivery to the
    tissues especially the brain and heart to
    maintain organ function and to treat the
    underlying cause.
  • Treatment must start promptly and be continued
    until
  • Tachycardia settles
  • The patient stops sweating
  • Level of consciousness improves
  • Urine flow is normal (0.5 1ml/kg/hr).
  • Peripheral perfusion improved (capillary refill
    time reduced).

9
  • To achieve the above
  • Ensure airway patency
  • Administer oxygen
  • Perform venepuncture with two(2) wide bore
    cannulae and administer appropriate fluids.
  • Take blood samples for investigations at
    venepuncture before connecting to fluids.
  • Pass a urinary catheter
  • If the patient lost more than water 1l of blood
    the patient will need blood transfusion.
  • For anaphylaxis add antihistamines, steriods,
    fluids and in severe cases adrenaline may be
    needed
  • Initial infusions should be Ringers Lactate or
    Normal saline

10
FLUIDS AND ELECTROLYTES
  • At birth body water is 75 of body weight.
  • From two(2) years upwards into adulthood body
    water is 60 in males and 55 in females.
  • 1/3 (14L) is extracellular 3.5L plasma
  • - 10.5L interstitial
  • 2/3(28L) is intracellular
  • Blood volume in an adult is 5L 3.5L plasma,
    1.5L red cells.
  • Blood volume in ml. Body weight (kg) x 80
  • In the first year of life blood volume is
    85ml/kg. body weight.
  • The most important electrolytes are sodium,
    potassium, calcium, magnesium, chloride, hydrogen
    ion and bicarbonate.
  • Sodium is the principal extracellular cation
    while potassium is the principal intracellular
    cation.

11
DISORDERS
  • Dehydration
  • Fluid overload (overhydration/ hypervolaemia)
  • Potassium imbalance
  • Sodium imbalance
  • Alkalosis
  • Acidosis
  • Electrolyte and fluid disorders may cause
  • - confusion
  • - restlessness
  • - coma
  • - arrhythmias
  • - paralytic ileus

12
  • Patients at risk
  • - vomiting and diarrhoea
  • - coma or confusion
  • - heat stroke
  • - dysphagia
  • - an acute abdomen e.g peritonitis or
    obstruction
  • - post operative patients after abdominal
    surgery.
  • - N G tubes in situ
  • - renal failure
  • - haemorrhage
  • - eclampsia
  • - shock
  • - uncontrolled diabetes
  • - cardiac disease
  • - tetanus
  • - diuretic therapy

13
  • Dehydration and fluid overload are best
    diagnosed clinically and hydration is also best
    assessed clinically.
  • Electrolyte disorders are very difficult to
    diagnose without laboratory investigations.

14
MANAGEMENT OF FLUID AND ELECTROLYTE IMBALANCE
  • Maintenance requirements
  • Abnormal losses from N-G tubes, drains, fistulae
  • Existing deficits

15
  • The following questions need answered before
    starting treatment.
  • What is the patients weight?
  • What is the patients normal circulating blood
    volume?
  • What are the normal maintenance and fluid and
    electrolyte requirements?
  • What are the normal plasma values of the
    electrolytes.
  • What are the abnormal losses to be replaced
  • Estimate continuing losses
  • Good fluid balance charts which can be readily
    understood and which make calculations easy are
    essential.
  • Insensible loss or unseen losses of fluid are
    approximately 0.5ml/kg/hr.
  • 1g KCl 13.5mmol
  • 1 ampoule KCl 1.5g 20mmol

16
  • Fluid secretion in G.I tract
  • Saliva 0.5 1L
  • Stomach 1.0 2.5L
  • Bile 0.5L
  • Pancreatic 0.75L
  • Small Large intestine 2.0 4.0L
  • Fluid loss from the G.I tract can easily reach 9L
    or more.
  • I.V fluids are given for 4 main reasons
  • For resuscitation
  • For rehydration
  • To give maintenance fluids
  • To keep a vein open for drug therapy

17
  • TYPES OF FLUIDS
  • Crystalliods Ringers Lactate, normal saline,
    Baddoes solution, dextrose saline
  • Colliods Dextran, hetastarch, albumin, blood
    products.
  • Most common and important electrolyte imbalance
    involve - potassium hypokalemia (lt3.5mmol/l) and
    hyperkalemia (gt5.5mmol/l). Both can produce
    cardiac arrest. For emergencies these need to be
    aggressively corrected.
  • sodium Hyponatraemia ( lt135mmol/l)
  • - Hypernatraemia (gt150mmol/l)
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