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SHOCK

IN MULTIPLE INJURY

PKI 5002
Definition

Acute circulatory failure with inadequate


tissue
perfusion resulting in generalized tissue
hypoxia.
Homeostasis
• Adequate cellular oxygenation depends on
– Red cell oxygenation
• Oxygen delivery to alveoli
• Oxygen exchange with blood
– Red cell delivery to tissues
• Adequate perfusion
– Blood volume
– Cardiac output
• Hb levels
• Distance between capillaries and cells
Pathophysiology
Inadequate tissue perfusion causes:
 Generalized cellular hypoxia
 Shift from aerobic to anaerobic metabolism
Aerobic Metabolism

6 CO2
6 O2

6 H2O
GLUCOSE
METABOLISM
36 ATP

HEAT (417 kcal)


Anaerobic Metabolism

2 LACTIC ACID

2 ATP
GLUCOSE
METABOLISM
HEAT (32 kcal)
CONSEQUENCE OF ANAEROBIC
METABOLISM
Inadequate cellular
Oxygen delivery

Inadequat
e energy Lactic acid
Anaerobic
production production
metabolism

Metabolic Metabolic
Cell Death
failure acidosis
The three essential patterns of circulatory
shock
SHOCK SYNDROMES
• Hypovolaemic Shock
– blood VOLUME problem
• Cardiogenic Shock
– blood PUMP problem
• Distributive Shock
– blood VESSEL problem
Hypovolemic Shock
• = “Low Volume ”
• Aetiology:
–Internal or external fluid loss
–Intracellular and extracellular compartment
• Most common causes:
–Haemorrhage
–Dehydration (non-haemorrhagic)
Pathophysiology Hypovolaemic Shock
Decreased intravascular volume

Decreased venous return

Decreased ventricular filling

Decreased stroke volume

Decreased CO

Inadequate tissue perfusion!!!!


Signs of severity
• Grade 1
Up to about 15% loss of effective blood volume
(~750ml in an average adult who is assumed to
have a blood volume of 5 liters)
This leads to a mild resting tachycardia
 Usually, no changes in BP, pulse pressure, or
respiratory rate occur.
 A delay in capillary refill of longer than 3 seconds
corresponds to a volume loss of approximately
10%.
Cont
• Grade 2
– Between 15-30% loss of blood volume
– 750-1500ml
– a moderate tachycardia (rate >100 beats per
minute), tachypnoea, decrease in pulse pressure,
cool clammy skin and begin to narrow the pulse
pressure.
– The time taken for the capillaries to refill after 5
seconds of pressure will be extended.
cont
• Grade 3
– 30 - 40% loss of effective blood volume
– 1500 - 2000 ml
– the compensatory mechanisms begin to fail
– hypotension and tachycardia
– low urine output (<0.5ml/kg/hr in adults)
– most of these patients require blood transfusions,
but the decision to administer blood should be
based on the initial response to fluids
cont
• Grade 4
– At 40-50% loss of blood volume
– 2000 -2500 ml
– Symptoms include the following: marked tachycardia,
decreased systolic BP, narrowed pulse pressure (or
immeasurable diastolic pressure), markedly decreased (or
no) urinary output, depressed mental status (or loss of
consciousness), and cold and pale skin.
– This amount of hemorrhage is immediately life
threatening.
Management hypovolaemic shock

• Hemorrhage control
• Restore volume
• Optimize oxygen delivery
– Enough circulating red cell
– Red cell oxygenation
– Red cell delivery
Fluid Resuscitation
• Crystalloids
– Such as sodium chloride (0.9%) or
– Lactated Ringer’s solution (Hartmann's solution)
– Dextrose solutions which contain free water are
less effective at re-establishing circulating volume
and promote hyperglycemia.
cont
• Colloids
– For example, polysaccharide (Dextran), polygeline
(Haemaccel), succinylated gelatin (Gelofusine) and
hetastarch (Hespan).
– Much more expensive than crystalloid solutions
• Combination
– colloids and crystalloids
• Blood
– Essential in severe hemorrhagic shock, often pre-
warmed and rapidly infused
Cardiogenic Shock
• The impaired ability of the heart to pump
blood
• Pump failure of the right or left ventricle
Etiology Cardiogenic Shock
• Pump Failure • Obstructive
– Acute M I (Mechanical flow
– CHF obstruction)
– Bradyarrhythmias – Tension
– Tachyarrhythmias pneumothorax
– Cardiomyopathy – Pulmonary embolism
– Cardiac tamponade
Pathophysiology Cardiogenic Shock
Impaired pumping
ability of LV

Decreased SV Inadequate systolic


Decreased CO emptying
Decreased BP Increased LV filling pressure
(preload)
Decreased tissue
perfusion !!!! Increased LA pressure
Increased pulmonary
capillary pressure
Pulmonary interstitial &
intraalveolar oedema!!!!
Management Cardiogenic Shock
• Goals: • Treatment is aimed at :
– Treat reversible – Early assessment &
causes treatment!!!
– Protect ischaemic – Optimizing pump by:
myocardium • Increasing
– Improve tissue myocardial O2
perfusion delivery
• Maximizing CO
DISTRIBUTIVE SHOCK
• Vasogenic • Neurogenic
• Septic • (Loss of sympathetic
• Anaphylactic tone)
• Spinal cord injury above T6
• Acute adrenal
insufficiency
Anaphylactic Shock
• Results from widespread systemic allergic
reaction to an antigen
• LIFE THREATENING
Pathophysiology Anaphylactic Shock
• Antigen exposure
• Body stimulated to produce IgE antibodies specific
to antigen
– drugs, bites, contrast, blood, colloid, foods,
vaccines, latex
• Reexposure to antigen
– IgE binds to mast cells and basophils
– Causes histamine release
• Anaphylactic response
Anaphylactic Response
• Vasodilatation
• Increased vascular permeability
• Bronchoconstriction
• Increased mucus production
• Increased inflammatory mediators
recruitment to sites of antigen interaction
Management Anaphylactic Shock
• Early recognition, treat aggressively
• Stop suspected drug
• Maintain airway: give 100% O2
• Lay flat & elevate feet
• IV Adrenaline
• Fluid resuscitation
• Antihistamines
• Corticosteroids
• Bronchodilators
DIAGNOSIS OF SHOCK
Based clinically on the presence of at least 2 of
following 4 criteria
– Hypotension
• SBP < 90 mmHg or
• MAP < 60 mmHg or
• SBP >40 mmHg from baseline
– Oliguria < 0.25 ml/kg/hour
– Cold, clammy skin and/or cloudy sensorium
– Metabolic acidosis
EXPOSURE
• Expose patient
• Quick survey from head to toe
• Do not forget patient’s back
• “Log roll” if ? C-spine injury
PRIMARY SURVEY
• Ask the patient directly
“How are you?”
• If patient gives a meaningful answer:
– The brain is reasonably functional
– There is an intact airway
– Ventilation is occurring
– Circulation is present
SECONDARY SURVEY
• Further history
• Head-to-toe & front-to-back examination
• Lab tests: ABG, clotting studies, and etc
• “X-ray everything that hurts”
• CT scan, only if stable
• Restoration of normal
RESUSCITATIO vital signs
• Adequate Urine output
N ENDPOINTS (0.5 - 1.0 ml/kg/hr)
• Adequate Cardiac Index
These endpoints • Normalization of
represent normal Oxygen delivery DO2I
hemodynamic • Normal Serum Lactate
parameters in levels
adults. • Blood lactate < 4 mmol/l
• Base deficit -3 to +3
mmol/l
• CVP = 15 mmHg

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