PTCPTC

shock

Lt. col. Dr. Zaman Ranjha

Associate prof. of Surgery

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ShockObjectives

To understand the structured approach to cerculatory problems

To recognize and manage shock

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Shock

Inadequate organ perfusion and tissue oxygenation

Most often due to hypovolaemia in surgery and trauma

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ShockAssessment

Blood pressure

Heart rate

Capillary refill

Peripheral temperature

Peripheral colour

Urine output

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Types of Shock

Hypovolaemic Cardiogenic Obstructive Neurogenic Endocrine Anaphylactic septic

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Severity of shock

Compensated

Vasomotor response

At the cost of skin, muscles and GIT. Acidosis beyond 12 Hrs- MOD

Decompensated

30-40% volume loss

Cadiopulmonary and renal compensation is knocked out

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ShockPathophysiology

Cellular

Autodigestive enzyme-cell lysis Microvascular

o2 free radical- endothelial damage Mode of death

rapid-cadiopulmonary

delayed-organ ischemia/reperfusion

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Hypovolumic shock

Fluid loss

less intake,

increased loss- vomiting, GIT, Renal

third space- pancreatitis

Blood loss

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ShockSites of blood loss

Closed Femoral # 1.5-2 litres

Closed Tibial # 500 ml

Pelvic # 3 litres

Rib # (each) 150 ml

Haemothorax 2 litres

Hand sized wound 500 ml

Fist sized clot 500 ml

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Shock Concealed blood loss

Abdominal Cavity

Pleural Cavity Femoral Shaft Pelvic Fractures Scalp (children)

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Types Of Bleeding

Compressible

- usually peripheral Non-compressible

- e.g. intra-abdominal

- Surgery required

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Shocksystemic effects

CVS.-Sympathomymatic

tachycardia-vasoconstriction

Resp. -compensatory respiratory alkalosis

Renal. Reduced perfusion, GFR, Urine

Na , H2o , conservation

Endocrine.Adrenal,cortisone =Na +water

catecholamine

Hypothalamus- vasopressin

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ShockClinical Signs

Altered mental state : anxiety to coma Pulse present ?

- radial systolic > 80 mmHg

- femoral systolic >70 mmHg

- carotid systolic > 60 mmHg Tachycardia Pulse pressure narrowed

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ShockClinical Signs

Skin - cold, pale, sweaty, cyanosed Capillary refill time > 2 seconds Blood pressure JVP Urine output < 0.5 ml/kg/hr Respiratory rate

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Clinical Signs In Shock

BloodLoss

Heart rate BloodPressure

CapillReturn

Resp Rate MentalState

<750 <100 Normal Normal Normal Normal

750-1500 >100 SystolicNormal

Prolonged 20-30 MildlyAnxious

>1500-2000

>120 Decreased Prolonged 30-40 AnxiousConfused

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Blood Loss < 750ml

Heart rate <100

Blood pressure normal

Capillary refill normal

Respiratory rate normal

Mental state normal

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Blood Loss 750-1500ml

Heart rate >100

Blood pressure systolic normal

Capillary refill prolonged

Respiratory rate 20-30

Mental state mild concern

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Blood Loss >1500ml

Heart rate >120

Blood pressure decreased

Capillary refill prolonged

Respiratory rate >30

Mental state axious/confused/coma

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Cardiogenic Shock

myocardial contusion cardiac tamponade tension pneumothorax penetrating wound of heart myocardial infarction Valvular heart disease arrhythmya

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ShockObstructive shock

Cardiac temponade Tension pneumothorax Pulmonary embolism

Reduced preload

Reduced cardiac out put

Engorged neck veins + oedma

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ShockEndocrine shock

May be combination of three Adrenal- hypovolumic

Hypothyroid- neurogenic

Hyperthyroid – high out put

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ShockDistributive shock

No volume depletion

1-Septic shock

Endotoxin-vasodilation-AV shunting-cellular hypoxia

2- Anaphylactic shock

Histamine- vasidilatation

3- Neurogenic- vasomotor

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Shock

?

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Shock Management

A + B, oxygen (if available) Two large bore intra-venous cannulae Stop obvious bleeding Fluid replacement Maintain temperature Analgesia

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ShockStop bleeding

Chest– Drain tube and re-expand lung– Emergency thoracotomy rarely

Abdomen– Laparotomy if hypotensive after fluids

Limbs– Pressure dressing – Tourniquet is last resort

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ShockFluid replacement

Warm fluids if possible Colloids or crystalloids? Consider hypotensive resuscitation if

haemostasis not secure- parallel with surgery

Consider oral resuscitation Resuscitation beneficial –dehydration

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ShockFluid replacement - How much?

1000-2000ml 0.9% Saline or Ringer’s

Reassess

1000-2000ml 0.9% Saline or Ringer’s

Reassess

Consider blood

Consider surgery

Aim for systolic BP>90 + HR <100

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Shock Consider blood Tx

Haemodynamic instability in spite of fluids

Haemoglobin <7g/dl and patient still bleeding

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Shock

?

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ShockSummary

Careful assessment Stop the bleeding Replace volume Correct the cause