Shock by

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Shock by
Dr . Zienb EL Matary
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Dif
Failure of adequate tissue perfusion that lead to
cell injury and death
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C/P -
All causes of shock causes hypotension and tachy
cardia

• depending on degree and duration
• Of shock patient may has abn . Mental
• State, urinary out put, tachy pnea , Finally
• Multiple organ dysfunction ( m. o. D) and
• Multiple organ failure (M. O. F. )

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Physiology

• Failure of heart to maintain C.O.P
  (cardiogenic shock).

2. Reduction in volume of blood in the
circulation in hemorrhage and dehydration.
3. Obstruction to circulation
(obstructive shock).
4. Loss of vascular tone in the circulation
system (distributive shock).
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• Treatment of shock must be directed to
  its cause .

• Sometimes it is difficult to diagnose the
  type immediately.

• There may be more then one type of shock.

• It is medical emergency and require
  immediate I.V fluids.

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CIP and types of shock
(1)- cardiogenic shock Main causes are
myocardial ischemia with or without
infraction.
(2) acute valvular dysfunction.
(3) cardiomyopathies.
(4)- persistant brady or tachy arrythemies.
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(2) hypovolemic shock In dehydration and
hemorrhage internal or external.
- Patient is cool and clammy.
- Neck viens are flat ,C.V.P
urine output and mental state is
affeced.
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(3)- obstructive shock As signifcant
obstruction to blood flow within
circulation from Rt to left side.
- Most common cause is massive pulm.
Embolism saddle embolus and acute pulmonary
hypertension.
- Other causes include pricardial temponade ,
constractive pricarditis which impair
diastolic filling of right ventricle.
- Tension pnumothorax and intrathoracic tumors
V.R
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(4)- Distrbutive shock Results from systemic
vasodilation which is so profound that even
normaly functionining heart can not increase
cardiac output to maintain blood pressure.
- Causes include mainly sepsis,
anaphylaxis, spinal injury.
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- In addition to impaired vascular tone
hypovolemia may occure in this type of
shock from interestial fluid losses due to
endothelial dysfunction.
- In more profound sepsis myocrdial
deression occures due to circulating
cytokins, T.N.F
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Treatment -
patient is hypoxic so O2 supply to all cases and
establish clear air way.

• start I.V fluids immediatly even if the cause of
  shock is not known , guided by C.V.P IN
  cardiogenic shock if C.V.P is so raised dont
• give I.V fluids ( C.V.P )

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TREATMENT OF CARDIOGENIC SHOCK

• most common cause ischemia ( MONA ).

• treatment of pulm . oedema.

• Treatment of arrythemias , electrolyte
  disturbauce.

• Acute revasclurisation ( thrombomlysis ,
  coronary by pass ).

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• If still hypotension, infusion of intropic
  factor dobutamin may be necessary (dopamin,
  dobutamin, phosphdiestrase inhibitor.).

• Intra aortic ballon counter pulsation pump in
  refractory cases.

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Teatment of hypovolemic shock
1. Restore fluid volume via wide bore I.V
cannula,without inducing pulm. Odema.
2. Blood transfusion ( 8 10gm Hb. ).
3. Frersh frozen plasma to obtain INR 1.5
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4. Plasme expandure agents ( albumin or starch
solution )
5. Treatment of cause of Hge. or dehydration
laparoscopy, endoscopy ,
embolisation.
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Treatment of distributive shock

• mainly due to sepsis .

• it has three main components

a Treatment of infection surgical drainge and
antibiotics Antibiotics
chosen initialy against all likely
causative organisms . ( need48h. Or more to
sterlize septicfocus
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• b. Adequate organ perfusion ( Hb conc , O2 stat ,
  C.O.P )
• Hb. Must be10 gm.
• O2 sat. higher than 92
• C.O.P by adminstration of fluids to C.V.P 14 to
  18 m.m.Hg.
• If serum albumin lt 2 gm , albumin infusion to
  intravascular oncotic pressure .
• May use inotropic agent to give supranormal
  C.O.P but not so benfecial.

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-If fluid therpy fail to B.P, therapy with
vaso pressor started as dopamin. if failed
we give nor epinephrin a more potent
vasopressor, Once B.P is maintained we can use
dobutamin
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C. Interuption of sequence leading to septic
shock early glucocorticoid therapy may be
used but found not affect morbidity or
mortality

• New focus to toxic madiators such as anti
  endotoxin , anti T.N.F may be used.

• antioxidant therapy by scavenging O2 free
  radicals in tissue injury

• Glutamin in nutirtional supplement musle
  catabolism

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Treatment of obstruetine shock

• pricardial temponade ( hypotension , Jugular
  pressure. Pulsus paradoxus ) pricardio
  centesis .

• treatmemt of pulm. Embolism by anticoagulants
  but massive one by thrombolytic therapy or
  even pulm embolectomy .

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Management of Shock in ER
Definition

Hypotension ,tachycardia abnormal
mental state, decrase
urine output and
finally mulitple organ failure.
Symptoms
. - Pallor
- Cold
extremities . - Cold clammy
skin . - Abnormal mental
state.
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First Aid Management
Measure blood pressure 90/60
pulse 90 beat/min
Assess Urinary output.

Mental state.
Call ICU doctor Do ABC
A Air way opening ( head
tilt and chin lift ). B
Breathing oxygen 1 L / min by nasal prong .
C Circulation I.V.
line and saline infusion .
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Thank you