In the name of GOD

Hypotention/shock

Reza ghaderi DR

1393-spring

DefinitionShock is a physiologic state

characterized by a significant reduction of systemic tissue perfusion, resulting in decreased oxygen delivery to the tissues.

This creates an imbalance between oxygen delivery and axygen consumption.

Tissue perfusion = cardiac out put * sys vascular resistance

C.O = heart rate * stroke volume

Stroke volume depend on preload, afterload, myocardial contractility

S.V.R depend on vascular length , vascular diameter , after load

Type of shock;

HypovolemicCardiogenicDistributive

Hypovolemic; decreased preload due to intravascular volume loss that resulting decreased cardiac output and P.C.W.P and increased S.V.R.ni

Cardiogenic; decreased cardiac contractility; pump failure; decreased C.O and increased S.V.R and P.C.W.P

Distributive; consequence of severely decreased S.V.R.

C.O increased for compensation and P.C.W.P may nl or low

Shock stages;Pre shock; reduction of 10% intra vascular

volumeWarmness, increased heart rate, peripheral

vasoconstriction

Shock; reduction of 25% intra vascular volume

Tachycardia, tachypnea, agitation, met acidosis, oligouria, sweating, cold skin

End organ damage; decreased C.O

Clinical manifestation

Hypotention ;that present in all type of shockSys BP<90 or more than 40mmHg reduction in base

Decrease level of conciseness ; agitation to coma

Oliguria; due to blood shifting toward principal organsCool and clammy skin; due to blood shifting to vital

organsMetabolic acidosis; due to decreased clearance of

lactate in liver, kidney , skeletal muscle.

Associated finding;Hematemesis, hematochesia , melena ,

vomiting , diarrhea , abd pain , trauma , post operation state

P/E;Dry skinDry axilla

Decreased skin turgorDecreased HbDecreased J.V.P

Increased amylase and lipase

Cardiogenic shock; chest pain, dyspnea , palpitation , C.V.D Hx, crackle , mur mur , gallop, increased JVP, ECG, cardiac marker ,

Distributive shock; dysuria, productive cough, dyspnea, hematuria, rash, fatigue, pain, tachypnea, tachycardia, increased W.B.C, photophobia

DDX;Hypovolemic shock categorized to two group

Hemorhagic shock: trauma, gi bleeding, rupture of hematoma, hemorrhagic pancratitis, FX , rupture of aneurism ,

Loss of volume; diarrhea, vomiting, heat, burn, small intestine obstruction, pancratitis, cirrhosis ,

Cardiogenic shock categorized to four groups;Myopathic; dilated cardiomyopathy, MI>40% LV

surface, RVMi , multi vessel diseaseArrhythmia ; AF, Flutter, V.T, bradyarrhythmia , C.H.B

Mechanical; valvular , mixom, V.S.DObstructive; extra cardiac; P.T.E, C.P, tamponad,

severe PAP

Distributive;Septic shock, T.S.S, SIRS, anaphylaxis , drugs,

toxin, bites, transfusion, adrenal crisis, post CPR

Approach;HXP/E

LabsMortality; 35-60% in septic shock

60-90% in cardiogenic shock variable in hypovolemic shock

Management; Hypovolemic; rate of resuscitation

choice of fluid

Cardiogenic

distributive

Good luck