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SHOCK

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SHOCK SHOCK DEFINTION The common denominator in all forms of shock is inadequate capillary perfusion. Shock is Characterized by Inadequate Tissue Perfusion and ... – PowerPoint PPT presentation

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Title: SHOCK


1
  • SHOCK

2
SHOCK DEFINTION
  • The common denominator in all forms of shock is
    inadequate capillary perfusion.
  • Shock is Characterized by Inadequate Tissue
    Perfusion and Cellular Hypofunction/Hypoxia.
  • Total body celular metabolism is malfunctional,
    usually by inadequate delivery of oxyden to meet
    celluar needs and occasionally of inability of
    cells to utilize oxygene( methemoglobinemia,
    carbon monooxide poisoning).

3
SHOCK
  • shock has been recognised for over 100 years, a
    clear definition is not estabilished till this
    moment, the definition of shock varies from time
    to time and has different meanings according to
    the etiological and pathogenetic factors, what
    caused it.

4
Classified by Etiologyby Mark A. Graber,
MDDepartments of Family Medicine and Emergency
Medicine University of Iowa College of Medicine
Peer Review Status Externally Peer Reviewed by
Mosby
  • Hypovolemic shock from volume loss (e.g.,
    dehydration, blood loss, burns)
  • Distributive shock based on loss of vascular
    tone (e.g., anaphylactic, septic, bacteremic,
    toxic, neurogenic shock).

5
Classified by Etiologyby Mark A. Graber,
MDDepartments of Family Medicine and Emergency
Medicine University of Iowa College of Medicine
Peer Review Status Externally Peer Reviewed by
Mosby
  • Cardiogenic shock based on pump failure( acute
    myocardial infarction, ventricular septal defect
    rupture, papillar muscles rupture, ventricular
    aneurysm, severe aortic stenosis, arrhythmias,
    trauma- tensione pneumothorax, pericardial
    temponade, cardic contusion
  • Dissociative shock based on inability of RBC to
    deliver oxygen
  • (e.g., methemoglobinemia, carbon monoxide
    posoning).

6
Most common clinical signs
  • Hypotension. Blood pressure drop is a late
    finding.
  • An orthostatic systolic decrease of 10 to 20 mm
    Hg or increase in pulse of 15 beats/min is
    considered "significant."
  • Take orthostatic vital signs recumbent and after
    standing for 1 to 2 minutes. Orthostatic vital
    signs may be normal in hypovolemic individuals,
    or nor-mal individuals may exhibit orthostatic
    changes so use clinical judgment and base
    treatment on symptoms. Alcohol ingestion, a meal,
    increased age, antihypertensives, etc. may cause
    orthostatic changes in BP and pulse in the
    absence of hypovolemia.

7
Most common clinical signs
  • Tachycardia usually present but may not be,
    especially in the presence of diaphragmatic
    irritation, which causes vagal stimulation, in
    neurogenic shock.

8
Most common clinical signs
  • Hypoperfusion including decreased urine output,
    decreased mentation, cool extremities, mottling,
    etc. Goal of resuscitation is to maintain urine
    output between 30 and 60 ml/hr.

9
Hypovolemic shock
  • Definition
  • It is present when marked reduction in oxygen
    delivery results from diminished cardiac output
    secondary to inadequate volume of whole blood.

10
Hypovolemic shock
  • The main causes are
  • - external bleeding
  • - internal bleeding
  • - the loss of big amount of plasma due to wide
    burns
  • - the loss of liquids and electrolytes after long
    lasting and hard diarrhea, vomiting
  • - an internal loss of liquids due to pleuritis of
    peritonitis, acute pancreatitis.
  • three last sometimes nemed as oligemic shock

11
Hypovolemic shock
  • Pathophysiology
  • diminishing cardiac output or fluid flow
    secondary to decreasing venous return

12
Hypovolemic shock
  • Clinicla signs
  • hypotensia, tachycardia, tachypnoe, oliguria,
    anxious, skin is pale and cool, often patient
    have nausea and vomiting, can be restless or
    comatose

13
Hypovolemic shock acording American Surgeons
Committee of Trauma 1988
14
Hypovolemic shock
  • Laboratory determination
  • arterial blood gases pH is considered normal
    7.35-7.45, PaCO2 35-45mm/ml, in pH lt7.35 is
    associated with a normal or less normal PaCO2
    -( metabolic acidosis)
  • in vomiting by stenosis of pyloric part of
    ventriculus - alcalosis
  • serum electrolytes in hemorragic shock near
    normal, in diarhhoe K?, vomiting Na?,
    pancreatitis Ca? ,K? and etc.
  • creatinine is usefule as an indicator of renal
    function

15
Hypovolemic shock
  • Treatment and menagemant of hypovolemic shock
    principles
  • monitoring of blood pressure, urination, breafing
    function, HR
  • replasment of blood volume ( Ringer lactate,
    solutions similar to plasma in electrolites
    composition, starch or gelatin solution, in
    bleading erythrocite mass
  • supplemental oxygene
  • after resuscitation surgery manipulations,
    interventionaly radiology, endoscopy, drugs.

16
Distributive shock
  • septic, bacteremic shock - based on loss of
    vascular tone, bacteremia and septic shock are
    closely related conditions.

17
Distributive shock
  • Bacteremic shock develops when hight amount of
    of bacteremia or fungs and its toxic agents
    penetrate into the blood and when the host
    defenses are decreased due to prolonged and hard
    infectional illness.

18
Distributive shock
  • Septic shock is sepsis with hypoperfusion and
    hypotension refractory to fluid therapy.
  • When bacteremia produces changes in circulation
    such that tissue perfusion is critically reduced,
    septic shock ensues.

19
Distributive shock
  • The main causes are
  • Septic shock is more often caused by
    hospital-acquired gram-negative bacilli and
    usually occurs in immunocompromised patients and
    those with chronic diseases.
  • In about 1/3 of patients it is caused by
    gram-positive cocci and by Candida organisms.
  • Shock caused by staphylococcal toxins is called
    toxic shock, a condition more frequently
    occurring in young women.

20
Distributive shock
  • Predisposing factors diabetes mellitus,
    cirrhosis, leukopenic states, especially those
    associated with underlying neoplasms or treatment
    with cytotoxic agents,
  • antecedent infection in the urinary, biliary or
    GI tracts,
  • invasive devices- catheters, drainage tubes, and
    other foreign materials and prior treatment with
    antibiotics, corticosteroids, or ventilator
    devices.

21
Distributive shock
  • Septic shock occurs more often in newborns,
    patients gt 35 yr, pregnant women, and those
    seriously immunocompromised by underlying
    diseases or iatrogenic complications of
    treatment.

22
Distributive shock
  • Pathogenesis
  • The bacterial toxins generated by the infecting
    organisms trigger complex immunologic reactions
    a large number of mediators, including TNF,
    leukotrienes, lipoxygenase, histamine,
    bradykinin, serotonin, and IL-2, have been
    implicated in addition to endotoxin (the lipid
    fraction of the lipopolysaccharides released from
    the cell wall of gram-negative enteric bacilli).

23
Distributive shock
  • Warm shock initially, vasodilatation of
    arteries and arterioles occurs, decreasing
    peripheral arterial resistance with normal or
    increased cardiac output even though the ejection
    fraction may be decreased when heart rate
    increases.

24
Distributive shock
  • Cold shock later, cardiac output may decrease
    and peripheral resistance may increase. Despite
    increased cardiac output, blood flow to the
    capillary exchange vessels is impaired, and the
    delivery of vital substrates, especially O2, and
    the removal of CO2 and waste products are
    decreased. This decreased organ perfusion
    particularly affects the kidneys and brain, and
    subsequently causes failure of one or more of the
    visceral organs. Ultimately, cardiac output
    declines and the typical features of shock
    appear.

25
Distributive shock
  • Clinical signs
  • altered mental alertness, chacking chill, rapid
    rise of body temperature, BP decreased to lt 80mm
    Hg , the skin is warm (paradoxically warm
    extremities), tachycardia, tachyon, and oliguria
  • late cool, pale extremities with peripheral
    cyanosis and mottling are late signs, with
    progression, multiorgan failure involves the
    kidney, lungs, and liver disseminated
    intravascular coagulation (DIC) and heart failure
    may also occur.

26
Distributive shock
  • Laboratory determination
  • leucocytosis, with marcet shift to left,
    associated with a sharp decrease in platelet
    count to lt 50,000/µL, respiratory alcalosis,
    metabolic acidosis, toxic anemia, positive blood
    cultures.

27
Distributive shock - Managment
  • should be treated in an ICU, the following
    should be monitored frequently systemic
    pressure, arterial and venous blood pH, arterial
    blood gas levels, blood lactate level, renal
    function, electrolyte levels, and possibly tissue
    PCO2, urine output should be measured, usually
    with an indwelling catheter, as an indication of
    splanchnic blood flow and visceral perfusion,

28
Distributive shock - Managment
  • the CVP or pulmonary artery pressure should be
    measured, and fluid replacement should be given
    until the CVP reaches 10 to 12 cm H2O or until
    the pulmonary wedge pressure reaches 12 to 15 mm
    Hg,

29
Distributive shock - Managment
  • respiration should be supported with nasal O2,
    tracheal intubation or tracheostomy, and
    mechanical ventilation as necessary,

30
Distributive shock - Managment
  • parenteral antibiotics should be given after
    specimens of blood, body fluids, and wound sites
    have been taken for Gram stain and culture
  • prompt empiric therapy is essential, the choice
    of an antibiotic requires an educated guess based
    on the results of previous cultures from the site
    of the primary infection or on the clinical
    setting in which the primary infection occurred.

31
Rare cases of shock
  • Shock due to the hormonal insufficiency gl
    thyroydea, hipofhysis and etc. (type
    distributive shock)

32
Rare cases of shock
  • Neurogenic shock hypotension secondary to
    central nervous system dysfunction, it is result
    of dysruption of the sympathetic nervous system
    (type is distributive shock).
  • The main causes are trauma or lumbal ane-sthesia
    due to vasomotoric disfunction paralysis. It
    results in vaso-dilatation and decresed vascular
    resistence -gt blood insufficiency in a
    circulatory system.

33
Rare cases of shock
  • Neurogenic shock
  • The main causes are trauma or lumbal
    ane-sthesia due to vasomotoric disfunction
    paralysis. It results in vaso-dilatation and
    decresed vascular resistence -gt blood
    insufficiency in a circulatory system.

34
Rare cases of shock
  • Shock due to the hyperergic reactions -
    allergic reactions develope if the patients is
    hypersensitive to various antigenes (type
    distributive shock).
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