SHOCK
CAUSES AND
MANAGEMENT
DEFINITION
Condition in which arterial blood flow/perfusion
(Blood Pressure) is inadequate to meet tissue
metabolic needs(maintain normal funtion of vital
organs)
In a healthy adult :
Hypotension – arterial BP<90mmHg
Shock – arterial BP <60mmHg
Postural Hypotension- Drop in Systolic BP of 1020mmHg or increase in Pulse rate of >15 with
position change indicates hypovolemia
DIFFERENTIAL DIAGNOSIS OF
SHOCK
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4.
HYPOVOLEMIA
CARDIAC PUMP FAILURE
OBSTRUCTIVE
DISTRUBUTIVE - SYSTEMIC
VASODILATATION
GET HISTORY FROM RELATIVES
HYPOVOLEMIA
Loss of blood
(hemorrhagic shock)
External hemorrhage
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Trauma
Gastrointestinal tract bleeding
Internal hemorrhage
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Hematoma
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Hemothorax or hemoperitoneum
Loss of plasma
Loss of fluid and electrolytes
External
Vomiting
Diarrhea
Excessive sweating
Hyperosmolar states
diabetic ketoacidosis,
hyperosmolar nonketotic coma
Internal ("third spacing")
Peritonitis, Pancreatitis
Burns
Ascites
Exfoliative dermatitis
Intestinal obstruction
SYMPTOMS & SIGNS OF HYPOVOLEMIA –
Blood Loss
in a 70kg patient circulating blood volume is 5 liters
(approx 70 ml/kg)
Loss of Blood
15% (700-750 ml)- may produce little or no obvious symptoms
30% (1500ml) –mild tachycardia, tachpnoea and anxiety
30-40%-(1750ml) tachycardia (110-120beats per min) &
marked hypotension
40% (2000ml) is life threatening
Plasma-5%body wt=3,500 ml
Interstitial Fluid- 15% body wt = 10,500ml
Intracellular volume= 40% body wt= 28,000ml
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Hypovolemia from Diarrhoea/Vomiting- loss of
water & lytes
Thirsty
Passes small amounts yellow urine
Dizzy on sitting (postural hypotension – 5% body
wt loss =3500 ml Shock – 10% = 7000ml
Dry axilla & groin ( 1500ml water deficit)
Decreased tissue turgor- tongue has
furrows,skin folds on pinching it , sunken
eyeballs
Cool clammy extremities
Tachycardia
Weak or absent pulses
Empty neck veins in the supine position
Cardiogenic –Cardiac Pump
Failure
Myocardial Infarction
Cardiomyopathy
Dysrhythmia
Tachyarrhythmia
Bradyarrhythmia
Acute valvular dysfunction (especially regurgitant lesions)
Rupture of ventricular septum or free ventricular wall
SIGNS & SYMPTOMS OFSHOCK PRODUCED
BY PUMP FALURE HEART FAILURE
• Sudden onset in VT/VFib
• Chest pain in MI
• Absent heart sounds or severe
tachycardia
• Raised JVP
• Pedal oedema
• Basal lung rales
• Hepatojugular reflux
Obstructive shock -Decrease in
Cardiac Filling
Tension pneumothorax
Disease of pulmonary vasculature (massive
pulmonary emboli, pulmonary hypertension)
Pericardial disease (tamponade,
constriction)
Cardiac tumor (atrial myxoma)
Left atrial mural thrombus
Obstructive valvular disease (aortic or mitral
stenosis)
SYMPTOMS OF OBSTRUCTIVE
SHOCK
Raised JVP• Tension pneumothorax- absent breath
sounds
• Cardiac tamponade- distant heart sounds
• Cardiogenic shock
• Pulmonary embolism- chest pain,
dyspnoea,hemoptysis,swollen calf, h/o
immobilisation
• Fluid overload
Distributive shock
Decrease in Systemic Vascular Resistance - Vasodilatation
Septic shock
Anaphylactic shock,
Neurogenic shock
Acute adrenal insufficiency
Vasodilator drugs
Signs & Symptoms of Septic Shock
Usually gram-bacteria
(E.coli,Kleb,Pseuo,Prot.)
Fever with chills,
confusion,
hyperglycemia
in old/babies, diabetes, immunosuppressed,
H/o recent surgery/manipuation of
urinary,biliary,gynae system
S&S ANAPHYLAXIS
History of
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Atopy
Insect bite esp wasp/bees
Food (peanuts, fish, eggs, seafood),
Drugs (penicillin, blood products, iron inj,
aspirin, NSAIDS, vaccines
Urticaria,
Oedema of skin and mucous membranes
(angioedema),
Wheezing- bronchospasm
Stridor- laryngeal oedema
Generalised itching, rhinitis, conjuntival
redness
Neurogenic Shock
Causes–
spinal cord injury,
spinal anaesthesia,
vasovagal- pain/frighth/ofainting,bradycardia,
ASSESSMENT OF SHOCK PATIENT
Pt in Cardiac Arrest- call for help
MoniterV fib –shock
V tach- vagal manoeuvers- carotid sinus
massage
Adenosine-6mg iv fast followed by 5 ml
saline flush Rpt in 1-2 min 12mg
Flat line- CPR
ASSESSMENT OF SHOCK PATIENT
Check airway- clear of blood/vomitus
Start O2 or intubate if unconscious
Auscultate lungs for air entry
absent- tension pneumothorax / hemothorax? (percussion)
rales – cardiac failure?
rhonchi- anapyhlaxis? LVFailure
Auscultate heartdistant sounds- cardiac tamponade?
Murmurs- acute valve problems?
JVP
flat- hypovolemia
distended- cardiac failure?, PE,,Ten PT,,Cardiav Tamp?
AbdomenFullness or pulsatile mass( ruptured aneurysm?)
Tender – pancreatitis, perforation?
ASSESSMENT OF SHOCK PATIENT
BP on both arms- different –dissection of aorta
Fever- sepsis
Pt cold clammy- hypovolemia? Cardiac failure?
Hypovolemia signs- skin/tongue turgor, sunken
eyeballs,pallor
Pedal oedema- cardiac failure
Blood around mouth, malena? ( do PR)
Urticaria, wheals, soft tissue swelling
(anaphylaxis)
ASSESSMENT OF SHOCK PATIENT
Investigations
ABG
ECG
CXR
Blood tests-Hb,WBC,platelets, Lytes,Blood sugar
Creatinine,LFT, PT,PTT,Grouping & xmatch
Cultures- Blood,urine,sputum
ECHO
Ultrasound abd , CT head
TREATMENT- HYPOVOLEMIA
Diarrhoea. Vomiting
Insert 2 IV canulae (16 guage)-forearm,
groin, central line
Cut down
Head down position
Infuse normal saline or ringers lactatereplace ½ the loss
Insert Urinary catheter(Foley)- 1ml/kg
Keep assesssing – dec IV when BP >90 and
pt urinating
TREATMENT OF Heart Failure
Myocardial Infarction
MONA
Dopamine
Treatment of Pneumothorax
Insert chest tube in 2nd intercostal space in
midclavicular line
Heimlich valve
Treatment of Sepsis
Antibiotics
Correct cause of sepsis
IV Fluids-leaky capillaries
Treatment of Anaphylaxis
AirwayO2 mask/ intubate, / cricothyroidotomy with 14 guage canula or small
ET tube
Head down
IV line
Adrenaline 0.5 ml of 1:1000 soln IM
or 5ml of 1:10,000 soln IV(0.1ml /kg body wt in children) slowly at
1ml/min till Bp recorded
rpt every 10min acc to BP/pulse
Hydrocortisone- 100-300mg IV
H1 blockerantihistamine- promethazine 25-50mg IV Rpt 4-6hrly
Aminophylline IV for bronchospasm (250mg IV)
DOPAMINE
Acts on diff receptors at diff doses
Low dose- ( 0.5-2 microgm/kg/min) D1 on vascular
smooth muscle causes vasodilatation of renal,
mesenteric, cerebral, coronary vascular bed
Mod dose (2-5 microgm/kg/min) Beta1 receptorspositive ionotropic and chronotropic
High dose - > 5 microgm/kg/min) Alpha receptorsvasoconstiction and decrease blood flow
Hemodynamic calculations
CVP- = R atrial pressure = 1-7 mm Hg
Pulm art pressure 15-30/3-12 mmHg
PAWP= Pulm artery wedge pressure=3-12
mm Hg
Cardiac index = cardiac output 4-6 l/min
Body surface area
=2.8-3.6l/min/sq.m
( sp gr of Hg=13.7)