Shock

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Shock
(??)
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Introduction

• 1731?,Le Dran,??? ??????
• 1. ?????? 1895?,Waren,Crile ????????? ,????

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• the face is pale or cyanosis
• cold and clammy skin
• rapid and thready pulse
• oliguria
• apathy
• ?hypotension

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• 2. ?????????? ?World War ,????,????????????,????(
  ???lt80mmHg),?????,???
• 3.????????? 20??60??,Lillehei,??????????????????
  ??SAS????????????,??????????????,??????????
• 4. ?????????? 20??80????,??????,???????
  ????????,(?????)????????????

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shock??????????????????????????,??????????,?
??????????,???????????????????????????????? ?
Concept of shock
??????????,???????,??????????????????????,????????
???(?)????
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Secton 1
Causes and classification
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??Classification of Shock by Causes
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• 1?????? (Hemorrhagic Shock)
• blood loss ? hemorrhagic shock
  10 (15min)---???
  20--------------shock
  50--------------death fluid loss vomit.
  Diarrhea (collapse)
• blood loss, fluid loss ?ECBV ? ?cardiac output? ?
  Bp ? ???????,?? -?????????????shock?? pale ?
  clammy ? rapid and thready pulse ? oliguria
• ?????????

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2?????? (Burn Shock) ????pain,
plasma loss infection shock (late)

• 3? ????? (Traumatic Shock)
• ???? pain , hemorrhage

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• 4?????? (Infective Shock)
• ??????(septic shock)???????(endotoxic
  shock)
• 1) low-outputcold shock
• 2) high-outputwarm shock

??????????????(?TNF??)?????
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• 5?????? (Cardiogenic Shock)
• ??????????,????? ,Bp???????

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• 6?????? (Anaphylactic Shock)

??? ? ???????? ? ????
?????????????Bp ?
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• 7??????? (Neurogenic Shock)

????,????????? ? ????????? ????? PR ? ,??????,Bp
? ? Neurogenic shock ????????????? ???,?????
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?? Classification according to the pathogenesis
of shock development

• Common fundamental of shock development
• inadequate effective circulatory blood
  volume
• The major determinants of effective circulatory
  blood volume

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Effective Perfusion
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Shock Development
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Classification according to the pathogenesis of
shock development

• Hypovolemic Shock (???????)

• Vasogenic Shock(??????)

• Cardiogenic Shock (?????)

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• ? Hypovolemic shock
• blood volume ? ???????cardiac output? , Bp
  ? ? ???? ? ?? ? ??????? tissue perfusion
  ? ?
• ????CVP?CO?Bp,PR
• ? Vasogenic shock
• 20 /80
• causes?????????????,???????ECBV ?
• distributive shock/low-resistance shock
• ? Cardiogenic shock
• ??????? CO ??? ? ECBV ?
  ?????????(obstructive
  shock)

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??Microcirculatory Disorder ??Cellular and
Molecular Mechanism
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• ??Mechanism of microcirculatory disorder

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Construction and Regulation of Normal
Microcirculation

???(Microcirculation)?????????????????????,??????
?????
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? Direct pathway
? Arteriovenous shunt
? True capillary pathway
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???????????
? ???? ?????????

• ? ????
• ???CA,TXA2,Ang?,ET?
• ??? histamine, kinin, adenosine, lactic
• acid, PGI2, TNF, NO

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Cap?????????
Cap???? ???A??
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??????????? (??)

• MC????(PV)?Bp???,?MC?????????
• 1????? ? ?A??A????
• PR? ? ? Bp ? ?,
• ??????????
• 2??V?MC???,???V?????,blood??????MC?????Cap??,???
  ??????????
• 3???,?????????????,????MC?PV ??????????,????????,M
  C?PV ??

MC?PV ? ?
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• ?????????????????

• Sixty year of twenty century
• Lillehei classical experiments
• Dog, hemorrhagic shock

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Lillehei put forward hypothesis of
microcirculatory disorder

• Later on, more experiments and clinic
  observations further confirmed and enriched
• this theory.

Shock ?????????????????
?? ?,sympathetic-adrenal medulla system????????,
PR?????????????????? ?
Q?P.r4
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The Stages and Mechanisms of Microcirculatory
Disorder of Shock
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Compensatory stage of shock (early stage of
shock?ischemic anoxia phase)
Decompensatory stage of shock (shock
phase?stagnant anoxia phase)
Refractory stage of shock (irrversible
stage?microcirculatory failure stage)
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(?) Compensatory stage of shock

1. The Alteration of Microcirculation

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? ??????????
??
? ?????????gt????
? ??????????
? ?????, ????, ??????????
? ???????????????? ????
? ?????????????
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2. The Mechanism of Microcirculatory Ischemic
Anoxia
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??????
??-?????????
CA????
?-???? ?ß??
???????????????a??
v
v
?-??????
???????
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catecholamine endotoxin
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• Mechanisms
• ? Bp?
• pain
• endotoxin
• ? ??a?? ??????????
• ??ß?? ???A-V????
• ??????(A?,TXA2 ,ET etc.) ?????
• a?? ??Cap ?????????????
• ?MC????? ?,????, ??MC?????,????, ?????????

??-????? ??????
??CA(NE, Adr)?(??/???,
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3. The Effect of Microcirculatory Ischemic Anoxia
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(1) To maintain blood pressure
? Blood volume?
Auto blood transfusion ????????????
Auto fluid infusion ???????????
? cardiac output?(???????) ???,????,?????
? peripheral resistance?
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• (2) To maintain blood supply to heart and brain

??????????,?????
??
? ?????????????? a?????
? ???? ??????????
? BP????
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4. Manifestations of Microcirculatory Ischemia
Stage
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????
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(?) Stagnant Anoxia Stage
1. Microcirculatory Alteration on Stagnant
Anoxia Stage
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? ???????,????
? ?????????--???,?????, ????? ,
????,????
? ????????
? ??????????
? ????????,????,??
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2. The Mechanism of Microcirculatory Stasis

• ?????,?? ? ??? ? ????CA?????????????? ?????
• ?????,?? ? ??????? (??,??,????)? ?????
• ???????? ??????????????LPS??? ??Mf,
  ??TNF,NO????? ?????
• ????????????,????????????WBC?????????????????,??
  ????? ,RBC??, PL ??, ????
• ? ?Cap???gt???,????,????,
• MC???????????,

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3. The Effect of Microcirculatory Stasis
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Bp ?
????????,????,???? ?????????(lt50mmHg)
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4. The Symptom of Microcirculatory Stagnant Stage
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?????
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• ???,???????????,??MC?????
• ??????????????????
• ?????????? (???????????)
• ?????????????????????
• ????? ?(reversible decompensatory stage )

pause
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(?) Microcirculation Failure Stage
(irrversible stage?microcirculatory failure stage)
1. The Alteration of Microcirculation Failure of
Shock
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• ? ?????????, Cap????
• ?????
• No-reflow phenomenon
• ? ????????,????

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2? Manifestations

• (1)Circulation failure ????????? ??????
  ????,CVP ??
• (2) ??DIC

? DIC???????MC?????????? ???????????????????????
?(FDP)??????????????,???????????
DIC???????????,???MC??? ??????????????????
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(3)????????

• MC ????DIC??????? ????(ROS,??? ?,cytokine) ?
  ????????? MODS

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3. why is it refractory

• (1)Failure of vasoconstriction response
  ??????????????CA???????,???Bp??????

??ATP?, acidosis, NO
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(2) Formation of DIC

• Alteration of hemorheology ????????,???????,?hype
  rcoagulable status ????DIC???
• ? the activation of coagulaion
• severe anoxia, acidosis and LPS? VEC is
  damaged ? TF ??extrinsic coagulation pathway
  exposed collagen ??intrinsic coagulation pathway
  
• other causes induce the relaese of TF
• (?????)???? (?????)????????(??-?????????
  ??????????????/??????)?????????
• Imbalance of TXA2/PGI2 VEC injury? TXA2/PGI2?

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• ???????
• ????
• ??
• ????
• ???????????????????
• ??????????,?????????
• ?????????????????
• ?????????????,??????????
• ????????????????, ????????????????????????,
  ??????????????

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?? Cellular and Moleculer Mechanisms

• (?)Cellular damage
• (?)Inflammatory medium overflow
• (?)Activation of intracellular message pathway

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(?) Cellular injury

• 1? Membrane damage
• ????????????????,??, ?cell edema
• 2? Alteration of mitochondria
• ??????????????????? ? ATP?
• 3? Alteration of lysosome
• ??????????????????
• ???? ? ????,??????
• ??????????????????
• 4?Cell death
• necrosis, apoptosis

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(?)Inflammatory medium overflow

• Severe infection, trauma and shock??Mfand
  Neutrophil??inflammatory medium
• pro-inflammatory
• anti-inflammatory
• ?SIRS
• Systemic inflammatory response
  syndrome,?????????
• MODS
• Multiple organ dysfunction syndrome,
  ??????????

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(?)Activation of intracellular message pathway

• ????NF-?B pathway
• ???????(TNFa, IL-1,6), ???????????
• ????????? (mitogen-activated protein kinase,
  MAPK)
• ??????TNFa, IL-1ß, IL-8,10,12, iNOS, MCP-1,
  ICAM-1

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??Metabolic derangement

• oxygen consumption?,glycolysis?
• anabolism?,catabolism?

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?? Water, electrolytes and acid-base disturbance

• 1. Metabolic acidosis
• Anaerobic glycolysis? ? Lactic acid
• Liver dysfuntion? the transform of lactic acid
  into glucose?
• Poor renal perfusion ? impaired renal excretion
  of acid
• 2. Respiratory alkalosis
• Early stage increased ventilation
• 3. Respiratory acidosis
• Late stage shock lung ?Respiratory acidosis
• 4. Cellular edema
• Hyperkalemia
• 
  

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1. Hemorrhagic shock

• ????, ????
• ???
• ARF
• ?????/septic shock

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2. Infective shock

• ????????, G-?septic shock ???, LPS ?endotoxic
  shock
• ??????, ??????????
• ???? SIRS
• ?????
• 1) hypodynamic shock (cold shock)
• LPS?CA LPS?VEC TFH????
• 2) hyperdynamic shock (warm shock)
• NO, KATP??

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3. Anaphylactic shock

• ????, ????????, ????
• ????????
• ???????????, 5-HT, kinine, ?????, PAF, PGs ?
  ????, permeability?
• ? Bp ????????

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4. Cardiogenic shock

• ??????
• Bp????????
• ?????
• ??????? ???????SAS
• ?????????????????????????, ???????????????

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Concept

• SIRS (Systemic inflammatory response syndrome,
  ?????????) ?????????(???)????????????????????????
  ?????
• 2. MODS (multiple organ dysfunction syndrome,
  ??????????)?????????????????????,????????????????
  ??????????,????????????????
• SIRS, sepsis, septic shock and MODS ????????????

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??SIRS (?????????)

• ????????
• ??????????????????permeability?,tissue
  perfusion?, hypercoagulation ?MODS or death
• ??????
• ?Tgt38??Tlt36 ?
• ?HRgt90?/?
• ?Rgt20?/??PaCO2lt4.3kPa(32mmHg)
• ?WBCgt12109/L?WBClt 4109/L, ????WBC gt10
• ????4??2???????????SIRS?

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1. Causes ???? ??????

• 2. Stages
• ?????????
• ?
• ?????????????/????
• ?
• SIRS/CARS???? ??????,MODS
• (pro-, anti-inflammatory medium, P224
  table13-2,-3)

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??????????(CARS)

• Compensatory anti-inflammatory response
  syndrome, CARS
• ??????????????????????,????????????????????
• ????????????

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3. Mechanism (??)

• (1)?????????
• ??,????? ???????????????????????????SIRS?,???
  ?????????????????????????????
• (2)????????????
• LPS?????????? ,?????????????(NF-?B, MAPK
  pathway),????????????????????????????, ??????,??
  inflammarory cascade ?????????? inflammatory
  medium overflow

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??MODS multiple organ dysfunction syndrome
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1. ??
1) ?????(???)??????????
2)?????(???) ????????, ?????????????
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3. ?????????

• 1)pulmonary dysfunction
• ??MODS????????? ????????,?????ARDS ?progressing
  dyspnea, hypoxia, cyanosis, pulmonary edema
• ?????????????
• ???????????,?????????????
• ????????????????????????? ???,??????

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• ?????????(acute respiratory distress syndrome,
  ARDS)???????????????,???????????????????????????

• ARDS??????????????,???????????,???????DIC?????V/Q?
  ???,??????,?????

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2) Heptic dysfunction

• ??????
• A) ???????/???,??????????????
• B) Kupffer(85 of Mf)?????,OFR,????
• C) ???XO

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3) Renal dysfunction

• MODS???ARF, ?????????
• ??????, ????, ????????
• MODS?, ???ARF, ???????
• ????3???dysfunction without ARF,?????
  ???ARF,???????

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4) ?????????????? ?? (??/ORF/????/??)????????
????????? ?? ?? ????
Kupffer???? ????,???? ?????????
?????? G-??????? ????????
????
?????? MODS

??TNF?IL-1 ? ????(bacterial translocation) ??????
???????,????(?????????)??????,??????????,?????????
?
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5)Cardiac dysfunction
Mechanisms

• ??????

• ??????

• ???????????????

• ???DIC

• LPS?TNF-a????????????

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6)Others
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Section 6
Principles of shock treatment)
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???????
???????
1. ????? 2. ????? ???,??? ??CVP?
PAWP? ?? 3. ?????????? ????????????
????????????? ???? ????
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4. ??????? 5. ???????? 6. ???????? 7. ??????????
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Clinical example

• ??,?,40?,?????????????????2??
• ????????,??60/40mmHg,??130?/min,????,????????????
  ??1?????????????????????,??????500ml???24h???50ml.
  
• ?????Hb 90 g/L, pH 7.25,PaCO2 22mmHg ,HCO3_
  5mmol/L, ?????25?

1.??????????????????????? 2.?????????? 3.?????????
? 4.?????????
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• 1.???????????????????????
• 2.??????????
• 3.??????????
• 4.?????????

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THANKS!