Shock Management

SHOCK
MANGMENT
Shock is a life-threatening
condition of circulatory failure
objective
Definition
Types
Pathophysiology
Clinical feature
Mangement aspect
Definition
shock is a phisiological state characterized by
systemic reduction in tissue perfusion resulting in
decreased tissue oxygen delivery
Types pf shock :
Hypovolemic shock
Cardiogenic shock
Obstructive shock
Distributive shock
Hypovolemic etiology
Hemorrhagic Non-hemorrhagic
Trauma External fluid loss
Gastrointestinal Dehydration
Retroperitoneal Vomiting
Diarrhea
Cardiogenic etilogy Interstitial fluid redistribution
Thermal injury
Valvular heart disease Trauma
Myocardial infection Anaphylaxis
Cardiac arrhythmias
Cardiomyopathy
Obstructive etiology Anaphylactic etiology
Cardiac tamponade injections - Penicillins
Constrictive pericarditis Anaesthetics
Pulmonary embolism Stings
Tension pneumothorax Shelfish
Air embolism
Neurogenic etiology Septic etiology

Paraplegia Gram+
Quadriplegia Gram-
Trauma to spinal cord Fungi / virus
Spinal anesthesia Protozoa
Pathophysiology of shock
Cells switch from aerobic to anaerobic metaboism
lactic acid production
Cell function ceases & swells
Membrane becomes more permeable
Electrolytes & fluids seep in & out of the cell
Na+/k- pump impaired
Mitochondria damage / cell death

Compensatory mechanisms: SNS ,
adrenal response
neurohormonal respones stimulated by Hormonal: Renin -angiotensin system
baroreceptors
decreased renal perfusion
increased heart rate release renin-angiotensin
increased contractility vasoconstriction angiotensin II- potent vasoconstriction
increased preload & release aldosterone adrenal cortex
sodium & water retention
SNS - Hormonal: ADH
Osmoreceptor in hypothalamus are stimulated
ADH released by posterior pituitary gland
vasopressor effect to increase BP
Acts on renal tubules retain water
SNS - Hormonal: Adrenall cortex
Anterior pituitary releases ACTH

Stimulates adrenal cortex to release glucocorticoids
Blood sugar increase to meet increased metabolic
needs
Shock - Effects on organs
Heart - decrease CO / hypotension / myocardial
depressants
Lung - decrease gas exchange / tachypnoea /
pulmonary edema
CNS - perfusion decreased / drowsy
Blood - coagulation abnormalities / DIC
Renal - increase GFR / decrease urine output
GIT - mucosal ischemia / bleeding and hepatic /
increase enzymes levels
Stages of shock
Initial: the cell become leaky and switch to
aerobic metabolism
Non-progressive: (compensated stage)
attempt to correct the metabolic upset of
shock
Progressive : (decompensated stage )
eventually the compensatio will began to fail
Refractory: organ fail and the shock can no
longer be reversed
clinical features
features of shock depends on the degree of
loss of volume & on duration of shock
Types:
Mild shock
Moderate shock
Sever shock
manegment of shock
the goals of management are to restore normal mental
status, heart rate and blood pressure, good
peipheralperfusion, and adequate urine output
Precautions
If comensated shock is suspected treat promptly and
aggressively to prevent progression
All patients require a secure vascular access, oxygen
therapy, and cardiopulmonary monitoring
General care : ABC

Oxygen
Intravenous access
Basic life support as needed
monitoring
- pulse oximetry, ECG, BP
- Blood glucose testing
- monitor urine output (1- 2 ml/kg/h)
1. Hypovolemic shock
infuse a fluid bolus of 20 ml/kg of normal saline or lactated
ringer as rapidly as possible
several boluses may be required, no more than 60 ml/kg
Hemorrhagic shock may require blood (10 ml/kg ) to replace
ongoing losses plus controlling external bleeding
2- Cardiogenic shock
The diagnosis is sugested by
- History of cardiomyopathy or congenital heart disease
- Abnormal cardiac rhythm
- Rales, gallop, or friction rub
- Hepatomegaly
- chest radiographs may show cardiomegaly & pulmonary edema
Expert consulation is always madatory
A. myocarditis, cardiomyopathy, congenital heart disease
- an initial bolus of NS/LR may be given at volume of 5-10 l/kg
- reassess frequently for signs of cardiac failure
- inotropes (eg. dobutamine, dopamine )
B. Brady arrhythmia with poor perfusion
Cardio pulmonary resuscitation (CPR ) if heart rate less
than 60 /min despite oxygen and ventilation
If persist:
- epinephrine IV 0.01 mg/kg (0.1 ml/kg of 1:10 000 )
- atropine for increased vagal tone or heart block
C. tachy arrhythmia with poor perfusion

Supraventricular tachycardia
- vagal maneuvers
- IV line available / adenosine
- IV line unavailable or failed adenosine /
synchronized cardioversion (0.5-1 j/kg )
Ventricular tachycardia ( with pulses )
- stable; amiodarone or procainamide
- unstable; synchronized cardioversion ( 0.5-1 j/kg )
Ventricular defibrillation and pulseless ventricular tachycardia

- defibrillation shock 2 j/kg
- CPR
- defibrillation 4 j/kg
- CPR
- Alternate drug ( epinephrin, then amiodarone ) with
defibrillation
3. Obstructive shock
Obstructive CHD Tension pneumothrax Cardiac

tamponade
- needle - fluid bolus 20ml/kg
- PGEI infusion
decompression NS or LR
- expert consultation
- tube thoracostomy -pericardiocentesis
4.Distributive shock
Anaphylactic
Neurogenic
- fluid bolus 20 ml/kg NS or LR
- vasopressor
Septic shock
- push repeated fluid boluses unless rales, respiratory distress or
hepatomegaly develop
- correct hypoglycemia and hypocalcemia
- administer first dose of antibiotics STAT
- consider STAT vasopressor drip and stress dose of
hydrocortisone
- if shock is fluid resistance start vasopressor to correct perfusion
. normotensive --- Dopamine
. hypotensive vasodilation (warm shock ) --- Norepinephrine
. hypotensive vasoconstriction ( cold shock ) --- Epinephrine
. consider transfusion to hemoglobin greater than 10 /dl, more
boluses and milrinone

Shock Management

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SHOCK

Neurogenic etiology Septic etiology

lactic acid production

Cell function ceases & swells

Membrane becomes more permeable

Electrolytes & fluids seep in & out of the cell

Na+/k- pump impaired

Mitochondria damage / cell death

SNS - Hormonal: Adrenall cortex

Anterior pituitary releases ACTH

General care : ABC

C. tachy arrhythmia with poor perfusion

Ventricular defibrillation and pulseless ventricular tachycardia

Obstructive CHD Tension pneumothrax Cardiac

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