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SHOCKSHOCK

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S. VimalaS. Vimala

SHOCKSHOCK

DefinitionDefinition:: Acute wide spread impaired tissue Acute wide spread impaired tissue

perfusionperfusion Circulatory collapse which leads to Circulatory collapse which leads to

hypoperfusion & hypoxiahypoperfusion & hypoxia Cellular, metabolic and Cellular, metabolic and

hemodynamic disarrangements hemodynamic disarrangements occuroccur

ShockShock

Shock is defined as inadequate Shock is defined as inadequate perfusion to the tissues of the bodyperfusion to the tissues of the body

The body isn’t getting enough The body isn’t getting enough oxygen or nutrients to feed itself. oxygen or nutrients to feed itself.

There are different types of shock There are different types of shock and though they are all similar, they and though they are all similar, they act upon the body in different ways.act upon the body in different ways.

Clinical Manifestations: Clinical Manifestations: of Shockof Shock

Differ according with the stageDiffer according with the stage Try to improve tissue perfusion:Try to improve tissue perfusion:

Depends on how much O2 is Depends on how much O2 is available available If it is transported to the tissues If it is transported to the tissues If they are able to use it.If they are able to use it.

Clinical Manifestations: Clinical Manifestations: of Shockof Shock

This is affected by: Hb level, This is affected by: Hb level, cardiac output and pulmonary gas cardiac output and pulmonary gas exchangeexchange

Hb and cardiac output are going to Hb and cardiac output are going to depend on the HR, preload, depend on the HR, preload, afterload and contractilityafterload and contractility

How does it happen?How does it happen?

Shock is a process that happens on a Shock is a process that happens on a cellular level. cellular level.

Most forms of shock are caused by Most forms of shock are caused by inadequate delivery, which means inadequate delivery, which means the body doesn’t have the adequate the body doesn’t have the adequate amounts of oxygen or nutrients it amounts of oxygen or nutrients it needs to surviveneeds to survive

How does it happen?How does it happen?

Some are caused by Some are caused by inadequate utilization, inadequate utilization, meaning the body has what it meaning the body has what it needs to survive, it just needs to survive, it just doesn’t know how to use it. doesn’t know how to use it.

Shock, if not quickly Shock, if not quickly recognized and rapidly recognized and rapidly reversed, will be fatal. reversed, will be fatal.

ShockShock

CausesCauses:: Decrease volume or loss of Decrease volume or loss of

intravascular volume (Hypovolemic)intravascular volume (Hypovolemic) Decrease cardiac output or Impaired Decrease cardiac output or Impaired

myocardial function (Cardiogenic)myocardial function (Cardiogenic) Maldistribution of intravascular Maldistribution of intravascular

volume (Distributive)volume (Distributive)

Maldistribution of intravascular Maldistribution of intravascular volume (Distributive)volume (Distributive)

Severe antibody antigen reaction Severe antibody antigen reaction (Anaphylactic)(Anaphylactic)

Loss of sympathetic tone Loss of sympathetic tone (Neurogenic)(Neurogenic)

Microorganisms invading body Microorganisms invading body systems (Septic)systems (Septic)

The Four (4) Stages of ShockThe Four (4) Stages of Shock

Initial StageInitial Stage: : cardiac output, cardiac output, impaired tissue perfusion. impaired tissue perfusion.

As blood supply to tissues As blood supply to tissues aerobic metabolism for a short aerobic metabolism for a short period period anaerobic metabolism to anaerobic metabolism to get some energyget some energy byproducts are byproducts are producedproduced acid lactic formation acid lactic formation cellular damagecellular damage

Initial StageInitial Stage

CO CO

Impaired tissue PerfusionImpaired tissue Perfusion

Anaerobic MetabolismAnaerobic Metabolism

Lactic acidemiaLactic acidemia

Cellular damageCellular damage

STAGES OF SHOCK STAGES OF SHOCK Stage of CompensationStage of Compensation

Stage of Compensation (sympathetic Stage of Compensation (sympathetic activates activates cool, pupils dilated etc) cool, pupils dilated etc)

Pathway:Pathway:• Decreased cardiac output leads to Decreased cardiac output leads to

reflex sympathetic stimulation reflex sympathetic stimulation causing increase HR and peripheral causing increase HR and peripheral vasoconstrictionvasoconstriction

STAGES OF SHOCK STAGES OF SHOCK Stage of CompensationStage of Compensation

PathwayPathway BP rises and skin is cold and clammy BP rises and skin is cold and clammy

due to peripheral vasoconstrictiondue to peripheral vasoconstriction Urine output drops (oliguria) due to Urine output drops (oliguria) due to

renal artery vasoconstrictionrenal artery vasoconstriction

Stage Of CompensationStage Of Compensationcont.cont.

Compensatory StageCompensatory Stage: the body is : the body is trying to improve the tissue perfusion. trying to improve the tissue perfusion. The sympathetic NS The sympathetic NS Neural, Neural, hormonal & chemical responses.hormonal & chemical responses.

NeuralNeural: : HR, HR, heart contractility, arterial heart contractility, arterial

and venous vasoconstriction and venous vasoconstriction blood is going to be shunted to blood is going to be shunted to the body organsthe body organs


HormonalHormonal: : Renin response Renin response angiotensin II angiotensin II

Aldosterone Aldosterone ADH this is going to ADH this is going to retain H2O and Na retain H2O and Na

Anterior pituitary Anterior pituitary ACTH ACTH adrenocortex is stimulated adrenocortex is stimulated glucocorticoids glucocorticoids glucose glucose

Adrenal medulla stimulation Adrenal medulla stimulation epinephrine & norepinephineepinephrine & norepinephine


ChemicallyChemically: : Epinephrine causes an increase in Epinephrine causes an increase in

HR/Cardiac contractility and HR/Cardiac contractility and therefore tissue perfusiontherefore tissue perfusion

Norephrine causes arterial Norephrine causes arterial vasocontriction and shunts blood vasocontriction and shunts blood away from non vital organs to vital away from non vital organs to vital organs.organs.

The response of the Pt is to The response of the Pt is to hyperventilate hyperventilate it tries to do is to it tries to do is to neutralize the lactic acidosisneutralize the lactic acidosis


NeurologicNeurologic

Sympathetic ChemoreceptorsSympathetic Chemoreceptors Vasoconstriction Vasoconstriction HR HR Rate/DepthRate/Depth Contractility RespirationContractility Respiration Shunting of Shunting of CO CO Blood Blood PaCo2 PaCo2

Tissue Tissue

Perfusion Respiratory AlkalosisPerfusion Respiratory Alkalosis

Stage Of CompensationStage Of Compensationcont.cont.EndocrineEndocrine

RAS ACTHRAS ACTH

Vasoconstriction Vasoconstriction Glucorticoid Glucorticoid

Na+ and H2 Na+ and H2

retention retention Serum Serum GlucoseGlucose

Stage of ProgressionStage of Progression Progressive StageProgressive Stage: the : the

compensatory mechanisms are compensatory mechanisms are starting to failstarting to fail

Na & K pump and the cellular membranes Na & K pump and the cellular membranes fail fail cellular death (rupture) and then cellular death (rupture) and then every system in the body is affectedevery system in the body is affected

Cardiac: Pt Cardiac: Pt ventricular failure ventricular failure Neurologically Neurologically cerebral hypoperfusion cerebral hypoperfusion Thermoregulation failureThermoregulation failure

Stage of Progression cont.Stage of Progression cont.

ComaComa Pulmonary Pulmonary Acute respiratory failure Acute respiratory failure Renal: ATN, renal vasoconstriction, renal Renal: ATN, renal vasoconstriction, renal

hypoperfusion hypoperfusion Disseminated Intravascular Coagulation Disseminated Intravascular Coagulation

(DIC)(DIC) GI: gram-negative bacteria enter into the GI: gram-negative bacteria enter into the

systemsystem Hepatic & pancreatic failureHepatic & pancreatic failure

Stage of Impaired Perfusion Stage of Impaired Perfusion (Progressive Shock)(Progressive Shock)

Pathway:Pathway: Prolonged vasoconstriction causes Prolonged vasoconstriction causes

irreversible ischemic injury. Adverse irreversible ischemic injury. Adverse effects that occur as a direct consequence effects that occur as a direct consequence of decreased perfusion:of decreased perfusion:

Anaerobic metabolism of glucose Anaerobic metabolism of glucose lactic lactic acidosisacidosis

Cell necrosis as in ATN Cell necrosis as in ATN acute renal acute renal failurefailure

Stage of Impaired Perfusion Stage of Impaired Perfusion (Progressive Shock)(Progressive Shock)

Acute alveolar damage Acute alveolar damage intra-alveolar intra-alveolar edema, hemorrhage and formation of a edema, hemorrhage and formation of a hyaline-fibrin membrane (Shock Lung) hyaline-fibrin membrane (Shock Lung) ARDSARDS

Anoxic necrosis of liver Anoxic necrosis of liver Nutmeg Liver Nutmeg Liver Ischemic necrosis of intestines Ischemic necrosis of intestines release release

of bacterial toxins of bacterial toxins worsening shock worsening shock

Stage of Decompensation Stage of Decompensation

Pathway: Pathway: Hypoxia and acidosis Hypoxia and acidosis failure of reflex failure of reflex

(sympathetic) peripheral vasoconstriction (sympathetic) peripheral vasoconstriction (vasodilation) (vasodilation) progressive hypotension progressive hypotension until perfusion of heart and brain reach until perfusion of heart and brain reach critical levelscritical levels

Prognosis for Shock depends upon cause Prognosis for Shock depends upon cause and stage at which treatment is begun and stage at which treatment is begun

Stage of DecompensationStage of Decompensation

Initial StageInitial Stage

Compensatory StageCompensatory Stage

Compensatory mechanism begin to failCompensatory mechanism begin to fail

Some irreversible cellular damageSome irreversible cellular damage


The shock cycle begins to perpetuate The shock cycle begins to perpetuate itselfitself

BP and blood flow can not be maintainedBP and blood flow can not be maintained Anaerobic metabolism cannot sustain Anaerobic metabolism cannot sustain

cellular activitycellular activity Irreversible cellular damage occursIrreversible cellular damage occurs Organ dysfunction appearsOrgan dysfunction appears

Refractory StageRefractory Stage

Refractory StageRefractory Stage: Irreversible: Irreversible MODSMODS multiple organ multiple organ

dysfunction syndrome dysfunction syndrome

Renal Renal hepatic hepatic pulmonary pulmonary cardiac cardiac

Critical Care NursingCritical Care Nursing

You live by the motto "to be right is You live by the motto "to be right is only half the battle, to convince the only half the battle, to convince the doctor is more difficult." doctor is more difficult."

Types of shock: Types of shock: HypovolemicHypovolemic: : Circulating or intravascular Circulating or intravascular

volume lossvolume loss HemmorhagicHemmorhagic

CardiogenicCardiogenic: inability of the heart to pump: inability of the heart to pump DistributiveDistributive: maldistribution of circulating blood : maldistribution of circulating blood

volumevolume SepticSeptic AnaphylacticAnaphylactic Neurogenic: loss of sympathetic toneNeurogenic: loss of sympathetic tone

TYPES OF SHOCKTYPES OF SHOCK

Hypovolemic – decreased volume in Hypovolemic – decreased volume in circulation due to:circulation due to:Severe hemorrhageSevere hemorrhageGI lossesGI lossesLosses secondary to wound of Losses secondary to wound of

surgerysurgeryBurnsBurns

Hypovolemic ShockHypovolemic Shock

This is fluid loss in the This is fluid loss in the intravascular space. intravascular space.

It is the most common due to GI It is the most common due to GI bleeding, trauma.bleeding, trauma.

Two types: Two types:

Absolute and RelativeAbsolute and Relative


AbsoluteAbsolute: due to trauma, surgery : due to trauma, surgery of GI system (esophageal varices).of GI system (esophageal varices).

Blood, plasma Blood, plasma loss loss External loss of fluid External loss of fluid


RelativeRelative: rupture of spleen, arterial : rupture of spleen, arterial dissection, sepsis, hyponatremia, dissection, sepsis, hyponatremia, internal injuries that cause a shift internal injuries that cause a shift from the intravascular from the intravascular extravascular compartmentsextravascular compartments

Loss on intravascular integrityLoss on intravascular integrity capillary permeabilitycapillary permeability


PathologyPathology: : of venous return of venous return preload (stroke volume & cardiac preload (stroke volume & cardiac output) = Inadequate tissue output) = Inadequate tissue perfusionperfusion

Initially pt losses about a 15%, which Initially pt losses about a 15%, which is about 750 ml is about 750 ml

At 40% or greater::::: BIG TROUBLEAt 40% or greater::::: BIG TROUBLE


During the During the compensatory stage compensatory stage we we want to maintain cardiac output want to maintain cardiac output

Cardiac output = tachycardia, pulse Cardiac output = tachycardia, pulse narrows, narrows, diastolic pressure, diastolic pressure, tachypneatachypnea

ABGs reveal a respiratory alkalosis & ABGs reveal a respiratory alkalosis & hypoxemiahypoxemia


Urinary outputUrinary output Skin is pale, cool, delayed capillary Skin is pale, cool, delayed capillary

refillrefill Jugulars are collapse (flat)Jugulars are collapse (flat) Neurological: change in LOCNeurological: change in LOC


In the In the progressive stageprogressive stage we are we are going to see a 1500 – 2000 ml loss going to see a 1500 – 2000 ml loss

HR, myocardial ischemia HR, myocardial ischemia some some arrhythmiasarrhythmias

ABGs ABGs metabolic acidosis metabolic acidosis PCO2 PCO2 , , Bicarbonate Bicarbonate and PaO2 and PaO2


Pt Pt acute renal failure where BUN acute renal failure where BUN and creatinine and creatinine

When the organs start failing we are When the organs start failing we are going to see the pt becomes going to see the pt becomes hypotensive probably we have to hypotensive probably we have to administer dopamine, vasopressinadminister dopamine, vasopressin


In the In the RefactoryRefactory we are going to see we are going to see 2000 ml loss 2000 ml loss

Severe tachycardia and then Severe tachycardia and then bradycardiabradycardia

Preload (right atrial pressure) RAP Preload (right atrial pressure) RAP = CVP = CVP

Stroke volume Stroke volume tissue perfusion tissue perfusion Afterload Afterload SVR (systemic SVR (systemic

vascular resistance) vascular resistance)


ManagementManagement Prevent and correct the fluid lossPrevent and correct the fluid loss Restore tissue perfusionRestore tissue perfusion 2 peripheral accesses Large 2 peripheral accesses Large bore IV’sbore IV’s Triple lumen catheter Triple lumen catheter

(femoral or jugular))(femoral or jugular))

Administer appropriate fluidsAdminister appropriate fluids Watch for S/S of overload, monitor right Watch for S/S of overload, monitor right

atrial and PA pressuresatrial and PA pressures


Hypovolemic ShockHypovolemic Shock is similar to is similar to hemorrhagic shock. hemorrhagic shock.

The difference is the patient is losing The difference is the patient is losing body fluid rather than blood. body fluid rather than blood.

This body fluid is water and/or This body fluid is water and/or plasma. plasma.


This thickens the blood making it This thickens the blood making it difficult for the heart to put out difficult for the heart to put out enough volume to meet the demands enough volume to meet the demands of the body. of the body.

The most common causes of The most common causes of hypovolemic shock are severe hypovolemic shock are severe dehydration and severe burns. dehydration and severe burns.


Signs and symptoms are the same as Signs and symptoms are the same as hemorrhagic shock, but include:hemorrhagic shock, but include:

Collapsed veins in the extremities and Collapsed veins in the extremities and neck, neck,

Poor skin turgor Poor skin turgor Concentrated, dark, strong smelling urine. Concentrated, dark, strong smelling urine.

Hemorrhagic ShockHemorrhagic Shock

Hemorrhagic ShockHemorrhagic Shock is when is when the body is losing blood the body is losing blood volume. volume.

When it loses this volume, the When it loses this volume, the red blood cells which carry the red blood cells which carry the oxygen are depletedoxygen are depleted

Hemmorhagic ShockHemmorhagic Shock

The blood loss may be caused The blood loss may be caused from a traumatic source, and may from a traumatic source, and may be quite obvious because there is be quite obvious because there is a copious amount of blood around a copious amount of blood around the body; the body;

i.e. GSW’s , stab wounds, i.e. GSW’s , stab wounds, large lacerations, large lacerations,

amputations,etc. amputations,etc.


The traumatic source may also be The traumatic source may also be from blunt trauma where the injury from blunt trauma where the injury is an organ that has torn or is an organ that has torn or ruptured. ruptured.

This can be the result of being hit This can be the result of being hit with a blunt object like a baseball with a blunt object like a baseball bat, slamming into the steering bat, slamming into the steering wheel in a vehicle crash or falling wheel in a vehicle crash or falling any distance. any distance.


The solid organs of the body are The solid organs of the body are the organs that usually tear or the organs that usually tear or rupture from an impact. rupture from an impact.

The solid organs in the abdomen The solid organs in the abdomen are the liver and kidneys, spleen are the liver and kidneys, spleen (LUQ, under the rib cage), and (LUQ, under the rib cage), and appendix (RLQ). appendix (RLQ).


With a blunt trauma injury, the With a blunt trauma injury, the patient is losing blood inside their patient is losing blood inside their body. body.

A person can bleed into three areas A person can bleed into three areas of their body: the chest cavity, the of their body: the chest cavity, the abdominal cavity, and into both abdominal cavity, and into both thighs thighs

e.g. bilateral femur e.g. bilateral femur fractures. fractures.


Hemmorhagic shock can also be Hemmorhagic shock can also be caused from an atraumatic bleed caused from an atraumatic bleed commonly caused from bleeding commonly caused from bleeding ulcers. ulcers.


Signs and symptoms with Signs and symptoms with hemorrhagic shock are what most hemorrhagic shock are what most people think of as shock: people think of as shock:

low blood pressure (systolic below low blood pressure (systolic below 100), 100),

high pulse rate (above 120), and high pulse rate (above 120), and rapid respiratory rate (greater than rapid respiratory rate (greater than

32), 32), the skin will be pale or cyanotic, cold the skin will be pale or cyanotic, cold

and sweaty. and sweaty.

Cardiogenic ShockCardiogenic Shock

TYPES OF SHOCKTYPES OF SHOCK

CardiogenicCardiogenic : A form of shock : A form of shock resulting from the heart’s failure resulting from the heart’s failure to inadequately pump blood.to inadequately pump blood.

This results in inadequate This results in inadequate delivery of oxygenated blood to delivery of oxygenated blood to the periphery, there tissue the periphery, there tissue perfusion is also inadequate.perfusion is also inadequate.


Cardiogenic ShockCardiogenic Shock may result may result from many different etiologies:from many different etiologies:

Ventricular Ischemia caused byVentricular Ischemia caused byAcute MIAcute MIOpen Heart Surgery Open Heart Surgery

***** These are the most ***** These are the most common ******common ******


Structural DefectsStructural DefectsPapillary muscle rupturePapillary muscle ruptureCardiomyopathyCardiomyopathyPulmonary EmbolusPulmonary Embolus

DysrhymthmiasDysrhymthmias

Affect normal circulationAffect normal circulation


Signs and symptoms include Signs and symptoms include chest painschest painsshortness of breath with increased shortness of breath with increased

rateratecool, clammy skincool, clammy skinpale or cyanotic colorpale or cyanotic color


Coarse rales in the lungs Coarse rales in the lungs

Cardiac dysrhythmiasCardiac dysrhythmias

Hypotension Hypotension

tachycardiatachycardia


CO/CICO/CI

PA and PAWPPA and PAWP

SVRSVR

Cardiac EnzymesCardiac Enzymes

UOUO

Ineffective

Pumping

of Blood

Failure to eject Failure to eject blood blood

from ventriclesfrom ventricles

Increased Increased PulmonaryPulmonaryPressuresPressures

Pulmonary Pulmonary

CongestionCongestion HypoxemiaHypoxemia

Inadequate tissue perfusion

SVCO

Pathophysiology


Treat Underlying cause:Treat Underlying cause:Thrombolytics,angioplasty, Thrombolytics,angioplasty,

surgery,antiarrhythmics,electrical surgery,antiarrhythmics,electrical therapytherapy

Pumping effectivenessPumping effectivenessVasodilators, diurectics, inotropes, Vasodilators, diurectics, inotropes,

mechanical devicesmechanical devices


Improve tissue perfusion O2, activity Improve tissue perfusion O2, activity restriction,analgesics, sedativesrestriction,analgesics, sedatives

Monitor hemodynamics, enzymes, Monitor hemodynamics, enzymes, electrolytes, I&O, ABG’s, ECGelectrolytes, I&O, ABG’s, ECG

(Distributive shock)(Distributive shock) Anaphylactic Shock Anaphylactic Shock

Severe hypersensitive reaction Severe hypersensitive reaction which leads to (antigen – which leads to (antigen – antibody) response. antibody) response.

Tissue perfusion and shock Tissue perfusion and shock syndrome occurs as a syndrome occurs as a consequence consequence

Distributive Shock Distributive Shock Anaphylactic Shock Anaphylactic Shock

Risk factorsRisk factors Food allergiesFood allergies InsulinInsulin VaccinesVaccines DrugsDrugs Venoms (snakes, spiders etc)Venoms (snakes, spiders etc) Blood transfusionsBlood transfusions Environmental agentsEnvironmental agents Latex Latex

Distributive Shock Distributive Shock Anaphylactic ShockAnaphylactic Shock

It is an Ig E or non Ig E mediated response It is an Ig E or non Ig E mediated response Capillary permeabilityCapillary permeability BronchoconstrictionBronchoconstriction Excessive mucous production Excessive mucous production Coronary vasoconstrictionCoronary vasoconstriction InflammationInflammation Cutaneous skin reactionsCutaneous skin reactions Constriction of intestinal wall, bladder & Constriction of intestinal wall, bladder &

uterusuterus

Exposure

Antigen – Antibody response

IncreasedCapillaryPermeability Circulating

volume Decrease CO Inadequate Tissue perfusion

Vasodilation

Pathophysiology

Anaphylactic ShockAnaphylactic Shock

Treatment:Treatment: Maintain adequate airwayMaintain adequate airway

Consider mechanical ventilationConsider mechanical ventilation CirculationCirculation

insert large bore IV –give fluidsinsert large bore IV –give fluids Medications- Medications-

epinephrine, antihistamines, epinephrine, antihistamines, bronchodilators, steroidsbronchodilators, steroids

Educate patientEducate patient


It starts 15 – 30 minutes with generalized It starts 15 – 30 minutes with generalized itching, redness and angioedema. itching, redness and angioedema.

Give epinephrine Give epinephrine most prominent most prominent actions are on the heart, producing a rapid actions are on the heart, producing a rapid rise in blood pressure, increased strength rise in blood pressure, increased strength of ventricular contraction, increase in the of ventricular contraction, increase in the heart rate, and constriction of the heart rate, and constriction of the arterioles in the skin and mucosa.arterioles in the skin and mucosa.


Epinephrine relaxes the smooth Epinephrine relaxes the smooth muscles of the bronchi.muscles of the bronchi.

It elevates the blood sugar level by It elevates the blood sugar level by increasing hydrolysis of glycogen to increasing hydrolysis of glycogen to glucose in the liver, and at the same glucose in the liver, and at the same time begins the breakdown of lipids time begins the breakdown of lipids in fat cells. in fat cells.

Epinephrine has a suppressive effect Epinephrine has a suppressive effect on the adaptive immune system.on the adaptive immune system.

Distributive ShockDistributive Shock Anaphylactic ShockAnaphylactic Shock

EpinephrineEpinephrine It is the drug of choice in It is the drug of choice in

anaphylaxis.anaphylaxis. Dose: 0.1 mg/Kg of a 1:10000 dose, Dose: 0.1 mg/Kg of a 1:10000 dose,

usually given IV in 3 – 5 minutes usually given IV in 3 – 5 minutes push.push.

If pt is intubated we can put it down If pt is intubated we can put it down the tube.the tube.

Neurogenic ShockNeurogenic Shock

Neurogenic – rare occurrence Neurogenic – rare occurrence resulting from loss sympathetic tone resulting from loss sympathetic tone and is caused by an injury of the and is caused by an injury of the spinal cord above T6. spinal cord above T6.

Loss or suppression of sympathetic Loss or suppression of sympathetic tone, the onset is between minutes tone, the onset is between minutes but can last for days, weeks or but can last for days, weeks or months, depending on the causemonths, depending on the cause

Neurogenic Shock Neurogenic Shock (Distributive shock)(Distributive shock)

S/SS/S BPBP BradycardiaBradycardia Skin warm & dry Skin warm & dry Determine the cause to treat itDetermine the cause to treat it

Neurogenic ShockNeurogenic Shock

Signs and symptoms:Signs and symptoms: low blood pressure, low blood pressure, increased respiratory rate,increased respiratory rate, diaphragmatic breathing (quadriplegia diaphragmatic breathing (quadriplegia

(total loss of sensation and movement (total loss of sensation and movement from the neck down). from the neck down).

Rarely is neurogenic shock reversible. Rarely is neurogenic shock reversible.


Risk FactorsRisk Factors Spinal cord injuries above the level of Spinal cord injuries above the level of

T6T6 Spinal anestheticSpinal anesthetic Emotional stressEmotional stress

Pts with intractable painPts with intractable pain Pts with CN system dysfunctionPts with CN system dysfunction


Pathology Pathology When we loss sympathetic tone we When we loss sympathetic tone we

have:have: Massive peripheral dilatation Massive peripheral dilatation Impaired thermal regulation Impaired thermal regulation


Arterial and venous vasodilatationArterial and venous vasodilatation Venous return Venous return preload preload CVP CVP Arterial return Arterial return afterload afterload BP BP

SVR systemic vascular resistanceSVR systemic vascular resistance

Loss of sympathetic tone

Loss of thermoregulation

Massive Vasodilation

CO

Inadequate Tissue Perfusion

Bradycardia

Pathophysiology

Septic ShockSeptic Shock

Septic Shock – Secondary to gram Septic Shock – Secondary to gram negative sepsis due to negative sepsis due to endotoxemia causing direct toxic endotoxemia causing direct toxic vessel injuryvessel injury

Pathway:Vasodilatation leads to Pathway:Vasodilatation leads to peripheral pooling and relative peripheral pooling and relative hypovolemia and decreased hypovolemia and decreased perfusionperfusion


Septic ShockSeptic Shock is when an infection is when an infection has invaded the body and causes the has invaded the body and causes the cells to be unable to utilize oxygen cells to be unable to utilize oxygen and nutrients. and nutrients.

Often intense intravenous antibiotic Often intense intravenous antibiotic therapy is required and even then therapy is required and even then may not be effective. may not be effective.

PathologyPathology

Gram-negatives release endotoxins from Gram-negatives release endotoxins from their cell membrane as they lyse and die. their cell membrane as they lyse and die. Gram-positive bacteria release exotoxins Gram-positive bacteria release exotoxins throughout their life span. throughout their life span.

These toxins trigger the release of These toxins trigger the release of cytokines (proteins release by cells to cytokines (proteins release by cells to signal other cells) such as tumor necrosis signal other cells) such as tumor necrosis factor and the interleukins.factor and the interleukins.

They also activate phagocytic cells as the They also activate phagocytic cells as the macrophages. macrophages.

PathologyPathology

Microorganism invades the CNS & Microorganism invades the CNS & endocrinal systemendocrinal system

Sympathetic nervous system is stimulated Sympathetic nervous system is stimulated and release ACTH (epinephrine & and release ACTH (epinephrine & norepinephine, glucocorticoids, norepinephine, glucocorticoids, aldosterone, glucagons and renin) aldosterone, glucagons and renin) after after release release hypermetabolic state hypermetabolic state massive massive peripheral dilatation, form of microemboli, peripheral dilatation, form of microemboli, selective vasoconstriction & selective vasoconstriction & capillary capillary membrane membrane tissue perfusion, tissue perfusion, cellular cellular perfusion perfusion acid lactic as a result of acid lactic as a result of metabolic metabolismmetabolic metabolism

PathologyPathology

These complex chemical reactions These complex chemical reactions lead to multiple system effects lead to multiple system effects MODSMODS

Microorganism invasion Microorganism invasion inflammatory immune response inflammatory immune response endothelium damageendothelium damage cellular cellular hypoxiahypoxia

Septic Shock Septic Shock (Distributive shock)(Distributive shock)

Most frequentMost frequent Maldistribution of blood flow (some Maldistribution of blood flow (some

areas areas perfusion and on others perfusion and on others the the perfusion)perfusion)

Increased blood will occur to the heart, Increased blood will occur to the heart, brain, liver and adrenal glands.brain, liver and adrenal glands.

At the same time there’ll be a decrease At the same time there’ll be a decrease in blood to the skin, lungs, kidneys and in blood to the skin, lungs, kidneys and viscera.viscera.


It is a sepsis-induced shock with It is a sepsis-induced shock with hypotension despite adequate fluid hypotension despite adequate fluid replacement that producereplacement that produce• Mortality rate > 45% depending on the Mortality rate > 45% depending on the

population agepopulation age Primary source is gram-negative & Primary source is gram-negative &

positive bacteria , aerobes and positive bacteria , aerobes and anaerobes, fungi or viral.anaerobes, fungi or viral.

Gram-negatives are more frequentGram-negatives are more frequent


Risk FactorsRisk Factors DiabetesDiabetes MalnutritionMalnutrition Alcohol abuseAlcohol abuse CirrhosisCirrhosis Respiratory infectionsRespiratory infections HemorrhageHemorrhage Cancer Cancer SurgerySurgery


Risk FactorsRisk Factors Traumatic injuries with peritoneal Traumatic injuries with peritoneal

contaminationcontamination BurnsBurns Prolonged IV cannulationProlonged IV cannulation AbscessesAbscesses Multiple blood transfusionsMultiple blood transfusions


2 types: Exogenous and 2 types: Exogenous and Endogenous Endogenous

ExogenousExogenous (hospitals) (hospitals) EndogenousEndogenous (skin, GI track, (skin, GI track,

respiratory & GU, catheters, EGT, respiratory & GU, catheters, EGT, ETT)ETT)


Intrinsically: age of pt and Intrinsically: age of pt and comorbiditiescomorbidities

Extrinsically: Drug therapy, fluid Extrinsically: Drug therapy, fluid therapy and surgerytherapy and surgery

Similar to toxic shock syndrome Similar to toxic shock syndrome (tampons (tampons gram-positives caused gram-positives caused by staphylococcus aureus)by staphylococcus aureus)


Venous system dilate Venous system dilate preload preload both in right and left ventricles both in right and left ventricles

RVPRVP

afterload, afterload, SVR, SVR, BP BP


Signs and symptoms include: in early Signs and symptoms include: in early stages, high blood pressure, high stages, high blood pressure, high pulse rate and high respiratory rate, pulse rate and high respiratory rate, fever, chills, and sweats. fever, chills, and sweats.

In late stages, the opposite, low In late stages, the opposite, low blood pressure, low pulse rate, low blood pressure, low pulse rate, low respiratory rate and low body respiratory rate and low body temperature. temperature.

Three StagesThree Stages have been identified have been identified

EarlyEarly

HyperdynamicHyperdynamic

Compensated stage: Compensated stage:

StagesStages

EarlyEarly TachycardiaTachycardia Cardiac indexCardiac index Skin warm and flushedSkin warm and flushed Normal BPNormal BP

StagesStages

Hyperdynamic stageHyperdynamic stage As shock progressesAs shock progresses Diastolic BP Diastolic BP Pulse widensPulse widens Peripheral pulses are boundingPeripheral pulses are bounding Temperature can be normal, Temperature can be normal,

elevated or below normalelevated or below normal

StagesStages

Late Hyperdynamic, uncompensated Late Hyperdynamic, uncompensated Widespread organ dysfunction begins to Widespread organ dysfunction begins to

occuroccur BP BP hypotension hypotension Peripheral edema is more evidentPeripheral edema is more evident Labored TachypneaLabored Tachypnea Crackles Crackles pulmonary interstitial edema pulmonary interstitial edema Sputum copious, pink and frothySputum copious, pink and frothy

StagesStages Late septic shockLate septic shock BP BP 90 mmHg 90 mmHg Cold extremitiesCold extremities MODSMODS Urinary outputUrinary output Abdominal distentionAbdominal distention Absence of BSAbsence of BS Bleeding from invasive lines Bleeding from invasive lines Disseminated Disseminated

intravascular coagulation (DIC)intravascular coagulation (DIC)

StagesStages

Late septic shockLate septic shock MODSMODS PetechiaePetechiae Cardiac dysrhythmias Cardiac dysrhythmias ABGs:you will see hypoxemia, ABGs:you will see hypoxemia,

hypercapniahypercapnia Metabolic acidosis (Lactic acidosis)Metabolic acidosis (Lactic acidosis) COMACOMA

StagesStages

Shift to left of WBC (later)Shift to left of WBC (later) of glucose and the pt develops an of glucose and the pt develops an

insulin resistance insulin resistance Obtain blood cultures right away, Obtain blood cultures right away,

then initiate broad-spectrum then initiate broad-spectrum antibiotics, when results of the antibiotics, when results of the cultures return adjust the antibiotics.cultures return adjust the antibiotics.

TreatmentTreatment Triple antibiotics Triple antibiotics Without the right antibiotic Without the right antibiotic

endotoxins endotoxins aggravates the case aggravates the case Drugs: Drugs: Vasoconstrictors (dopamine or Vasoconstrictors (dopamine or

norepinephrine (Levophed))norepinephrine (Levophed)) Platelet aggregated antagonist Platelet aggregated antagonist ((Aspirin Aspirin

and NSAIDs *non-steroidal anti-inflammatory and NSAIDs *non-steroidal anti-inflammatory drugs):drugs):

Steroids shown Steroids shown nono benefit benefit

Post TestPost Test

Shock SyndromesShock Syndromes

1. True or False: Regardless of the 1. True or False: Regardless of the cause, Shock means inadequate cause, Shock means inadequate tissue perfusion.tissue perfusion.

TRUETRUE

List down the complication of shockList down the complication of shock

The EndThe End

shock sinai - copy

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