CRITICAL CARE
SHOCK
O2 Demand>O2 Delivery
TYPES:
PUMP FAILURE
CARDIOGENIC SHOCK
SEPTIC SHOCK
CONTAINER FAILURE
ANAPHYLACTIC SHOCK
NEUROGENIC SHOCK
FLUID FAILURE
HYPOVOLAEMIC
PATHOLOGY:
MANAGEMENT:
 Depends on type of cause
 Treat underlying cause
 Aim to restore oxygen delivery to tissues
SPECIFIC TREATMENTS (SURGICAL)
1. HYPOVOLAEMIC SHOCK
Haemorrhage: trauma, GI bleed, ruptured aneurysm
Dehydration:
bowel obstruction, d+v
Classification of haemorrhage
Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs
and fluid resuscitation is not usually necessary.
Class II Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardic (rapid
heart beat) with a narrowing of the difference between the systolic and diastolic blood pressures. The body
attempts to compensate with peripheral vasoconstriction. Skin may start to look pale and be cool to the
touch. The patient might start acting differently. Volume resuscitation with crystaloids (Normal Saline or
Lactated Ringer's Solution) is all that is typically required. Blood transfusion is not typically required.
Class III Hemorrhage involves loss of 30-40% of circulating blood volume. The patient's blood
pressure drops, the heart rate increases, peripheral perfusion, such as capillary refill worsens, and the
mental status worsens. Fluid resuscitation with crystaloid and blood transfusion are usually necessary.
Class IV Hemorrhage involves loss of >40% of circulating blood volume. The limit of the body's
compensation are reached and aggressive resuscitation is required to prevent death.
Principles of Trauma Management (ATLS)
PRIMARY SURVEY
A:
Airway and C-spine control (it does not matter how much blood there is
if patient cannot get oxygen into lungs !)
B:
Breathing
C:
Circulation
D:
Disability (nervous system)
E:
Exposure
SECONDARY SURVEY
General Management of Hypovolaemic Shock
 Stop the bleeding !
 Oxygen (increases oxygen delivery to tissues)
Oxygen delivery=cardiac output X Hb concn X O2 saturation




Fluid resuscitation: colloid vs crystalloid (NOT 5% dextrose EVER)
Catheterise (0.5ml/kg/hr urine output)
NG tube (not in suspected basal skull fractures)
Invasive monitoring (maybe ?)
Specific Causes and Management
Bleeding
Visceral injury, blunt or penetrating
Hepatic:
Spleen:
conservative vs surgical (packing)
conservative vs splenic preservation vs splenectomy (remember
pneumococcal prophylaxis)
Pancreas: conservative vs stent vs resection
GIT:
primary repair vs faecal diversion
Cardiac: primary repair
Pulmonary: conservative vs thoracotomy (>1.5L or more 200mL/hr for 2 hrs)
Great vessel:often fatal
RADIOLOGICAL METHODS (USA)
DAMAGE LIMITATION CONCEPT
GI Bleed
Upper GI:
Lower GI:
Aortoenteric:
Endoscopic vs surgical
Often conservative, radiological, surgical
rare, surgery possible but often fatal
Aneursym
Abdominal:
careful BP management (increase pressure, increase bleed)
Surgery
Endovascular stent (if you are very lucky, right time, right
place and right size stent !)
Thoracic:
Stent vs surgery
Require bypass
Dehydration
Bowel obstruction
Small bowel:
Hernia:
Adhesions:
Others:
Large bowel:
Volvulus:
Malignant:
Pseudo-obstruction:
“drip and suck”, resuscitate, reduce, repair
conservative vs surgical (rising WCC, peritonism)
often surgical
endoscopic, surgery if fails or intestinal ischaemia
surgery (defunction or resect)
colonic stent
medical (prokinetics, enemas, neostigmine)
endoscopic (colonoscopy)
surgery (caecostomy)
2. SEPTIC SHOCK
SIRS: SIRS can be diagnosed when two or more of the following are present




Heart rate > 90 beats per minute
Body temperature < 36 or > 38°C
Hyperventilation (high respiratory rate) > 20 breaths per minute or, on blood gas, a PaCO2 < 4.3 kPa
(32 mm Hg)
White blood cell count < 4000 cells/mm 3 or > 12000 cells/mm 3 (< 4 x 109 or > 12 x 109 cells/L), or the
presence of greater than 10% immature neutrophils.
SEPSIS: SIRS with infection
SEVERE SEPSIS: Sepsis with hypoperfusion ie. Septic shock
Causes
Visceral perforation
Urosepsis
Pelvic sepsis
Respiratory
General Management
Same as shock, only treat cause of sepsis
Fluid resuscitation
Antibiotic therapy (BLOOD CULTURES PRIOR TO THIS)
Involve critical care early: invasive monitoring
inotropic support
reducing mortality from sepsis now a national
priority