Shock

Dr. Abdullah M. Kaki, MB ChB, FRCPC

Department of Anesthesia, Faculty of Medicine, King Abdulaziz University

Objectives of the Lecture

To provide an up-to-date understanding of the types of shock

To understand the current pathophysiology of shock

To discuss some therapeutic options for shock

Definition

French term , Choc (Le Dran- 1743)

Systemic derangement in tissue perfusion leading to wide spread of cellular hypoxia and vital organs dysfunction.

37 yr male involved in RTA,(driver), brought to ER by ParamedicsBP 90/50 mmHg, HR 120/min, RR 28/minPerfuse sweating, pallor, tenderness over chest & upper abdomen What is wrong with him? D Dx?What LAB investigation is required for the Dx?What is your plan for treatment?

52 yr Diabetic female patient admitted with foot ulcer for debridement. 2 days later pt developed fever, confusion and they called you to assess the patient.

What is your approach?

What is plan for treatment?

22 yr male patient came to ER with renal colic, your colleague prescribed an antibiotic & pain killer for him.

On administration of his medicine,

he collapses.

What is your approach?

75 year old female admitted to the hospital 4 days ago with chest pain, S.O.B., diagnosed as MI & was started.

Early this morning the patient developed hypotension, tachycardia, SOB

What is wrong with her?

Types of Shock

Hypovolemic

Distributive

Obstructive

Cardiogenic

 Shock Features

Septic Cardiogenic Hypovolemic

Blood Pressure ↓ ↓ ↓

Heart rate ↑ ↑ ↑

Respiratory rate ↑ ↑ ↑

Mentation ↓ ↓ ↓

Urine output ↓ ↓ ↓

Arterial pH ↓ ↓ ↓

Is cardiac out[put reduced? No Yes Yes

Pulse pressure ↑ ↓ ↓

Diastolic pressure ↓↓↓ ↓ ↓

Extremities/ Digits Warm Cool Cool

Nailbed return Rapid Slow Slow

Heart sounds Crisp Muffled Muffled

Temperature ↑ or ↓ ↔ ↔

White cell count ↑ or ↓ ↔ ↔

Site of infection + + - -

Is the heart too full? No Yes No

Symptoms/clinical context Sepsis/liver failure Angina / ECG Hemorrhage/dehydration

Jugular venous pressure ↓ ↑ ↓

S3, S4, gallop rhythm - + + + -

Respiratory crepitation - + + + -

Chest X-ray Normal Large heart, ↑upper lobe flow, pulmonary edema

Normal

Pathophysiology of Shock

Oxygen Delivery:

PaO2

Hb

CO

CO = SV X HR

Compensatory & Decompensatory Mechanisms

Autonomic Nervous System

Hormonal mechanism

Peripheral Vascular system

Myocardial Depression

Transcapillary refill

Down regulation of Catecholamines receptors

The mainstay of shock therapy

Improving Oxygen Delivery: (by raising hemoglobin concentration, cardiac output, or arterial saturation).

Reduce Oxygen Consumption.

Identify and treat the precipitants of hypoperfusion.

Therapeutic Options

Early Diagnosis

Need for ICU

Identification of Cause

Prevention:

*Aseptic Technique * Monitoring

*Perioperative Antibiotics *Vaccination

Fluid Resuscitation

Colloids vs Crystalloids

Fluid replacement

Augmentation of SV

Fluid

Inotropes

Vasodilators

Future Directions

Better Outcome: Advanced monitoring and ICU facilities.

More patients: elderly, major surgeries, more infection & more invasive devices.

Outlook is bright as we are unrevealing the secrets of shock.