Diagnosis of shock Definition of Shock: Hypotension associated with hypoperfusion abnormalities.

Evidence of hypoperfusion includes - alteration in mental state, oliguria, organ dysfunction and lactic acidosis. Different types of Shock: 1. hypovolaemic 2. cardiogenic 3. distributive 4. obstructive Type of shock CVP/PCWP CO SVR clinically Hypovolaemic cold and shut down Cardiogenic cold and shut down Distributive /-/ warm and dilated Obstructive Management of Shock Ensure oxygenation and maintain perfusion Usually aim for MAP = 70-80mmHg u/o 0.5ml/kg/hr Hypovolaemic shock - due to inadequate circulating fluid volume - causes divided to haemorrhagic or non-haemorrhagic (major burns; gastrointestinal losses: vomiting, fistulas; urinary losses: diabetes, diabetes insipidus; evaporative losses with fever, abdominal surgery) - fluid resuscitation - colloid or crystalloid (do not use dextrose solution) - replace blood loss - review source of bleeding and stop bleeding Cardiogenic shock - causes acute myocardial infarction; myocardial contusions post-trauma; myocarditis; acute valvular dysfunction; post-cardiopulmonary bypass; cardiomyopathy - control arrhythmia, reverse myocardial ischaemia, specific treatment for myocarditis, open heart surgery for valvular repair - preload a trial of fluid may be warranted in diastolic heart failure (observe CVP/ BP /urine output and oxygenation) - inotropes dobutamine indicated to augment myocardial contractility in
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the presence of normal or slightly reduced blood pressure - afterload - vasodilator will cause further hypotension start noradrenaline to maintain perfusion - consider invasive monitoring pulmonary artery catheter - discuss with senior IABP and revascularization procedure may help Distributive shock - causes: septic shock; anaphylaxis; spinal shock; hyperthyroidism; severe liver dysfunction - fluids

- in our unit, the combination of agents usually used is dobutamine and noradrenaline; adrenaline for anaphylaxis - treat underlying cause e.g. sepsis Obstructive shock - causes cardiac tamponade; tension pneumothorax; pulmonary or air embolism - fluid resuscitation for temporary support - inotropes for temporary support - relief of obstruction e.g. pericardiocentesis for tamponade chest drain for tension pneumothorax thrombolysis, embolectomy Common inotropes and vasopressors used in our unit Drug Dilution and Dose adrenaline 3mg in 50ml NS (single strength) up to 8th strength used noradrenaline 3mg in 50ml NS (single strength) up to 8th strength used dobutamine 250mg in 50ml NS 2.5ug 10ug/kg/min i.e. 2-10ml/hr dopamine 200mg in 50ml NS 2.5ug 20ug/kg/min i.e. 2.5ml 20ml/hr phenylephrine 10mg in 500ml NS Not usually used in ICU/usually for neurosurgical patients start at to increase BP rapidly 100ug 180ug/min when BP normalizes maintain 40ug 60ug/min Use of steroids, vasopressin, activated protein C in septic shock discuss with ICU senior. (Activated protein C protocol available)
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Management of Shock
Shock is a serious medical condition where the tissue perfusion is insufficient to meet demand for oxygen and nutrients because the body is not getting enough blood flow. This can damage multiple organs and can get worse very rapidly. This hypoperfusional state is a life-threatening medical emergency and one of the leading causes of death for critically ill people. Major classes of shock include : 1. Hypovolemic Shock (caused by inadequate blood volume) Hypovolemic shock is an emergency condition in which severe blood and fluid loss makes the heart unable to pump enough blood to the body. This type of shock can

cause many organs to stop working. Blood loss can be due to bleeding from cuts or other injury or internal bleeding such as gastrointestinal tract bleeding. The amount of blood in your body may drop when you lose too many other body fluids, which can happen with diarrhea, vomiting, burns, and other conditions.

Management of Shock

Symptom are :

Anxiety, restlessness, altered mental state due to decreased cerebral perfusion and subsequent hypoxia. Hypotension due to decrease in circulatory volume.

A rapid, weak, thready pulse due to decreased blood flow combined with tachycardia. Cool, clammy skin due to vasoconstriction and stimulation of vasoconstriction. Rapid and deep respirations due to sympathetic nervous system stimulation and acidosis. Hypothermia due to decreased perfusion and evaporation of sweat.Thirst and dry mouth, due to

fluid depletion.Fatigue due to inadequate oxygenation. Cold and mottled skin (cutis marmorata), especially extremities, due to insufficient perfusion of the skin. Therapy are include : Maintain or increase intravascular volume, In hypovolaemic shock, caused by bleeding, it is necessary to immediately control the bleeding and restore the victim's blood volume by giving infusions of balanced salt solutions. Blood transfusions are necessary for loss of large amounts of blood (e.g. greater than 20% of blood volume), but can be avoided in smaller and slower losses. Hypovolaemia due to burns, diarrhoea, vomiting, etc. is treated with infusions of electrolyte solutions that balance the nature of the fluid lost.

Decrease any future fluid loss via I.V fluid regimen

Give supplementary O2 therapy to commence replacement of fluids via the intravenous route.

2. Cardiogenic shock (associated with heart problems) Cardiogenic shock is a disease state where the heart is

damaged enough that it is unable to supply sufficient blood to the body. Most common causes are : a). acute myocardial infarction b). dilated cardiomyopathy, This is a serious disease in which the heart muscle becomes inflamed (enlarged and stretched) and doesn't work as well as it should. c). acute myocarditis d). arrhythmias Symptoms are : similar to hypovolaemic shock but in addition:

Distended jugular veins due to increased jugular venous pressure.

Absent pulse due to tachyarrhythmia.

Therapy are include : The main goals of the treatment of cardiogenic shock are the re-establishment of circulation to the myocardium, minimising heart muscle damage and improving the heart's effectiveness as a pump.

Oxygen (O2) therapy to reduces the workload of the heart by reducing tissue demands for blood flow.

Administration of cardiac drugs

Increase hearts pumping action through medication such as Dopamine, dobutamine, epinephrine, norepinephrine, amrinone

3. Septic shock (associated with infections) Septic shock is a serious condition that occurs when an overwhelming infection leads to low blood pressure and low blood flow. The brain, heart, kidneys, and liver may not work properly or may fail. Most common of this case may its happened to the patients with Meningococcemia, WaterhouseFriderichsen syndrome, DIC (disseminated intravascular coagulation), Multiple organ dysfunction syndrome (MODS), Acute Respiratory Distress Syndrome (ARDS). Symtomps are : similar to hypovolaemic shock except in the first stages:

Pyrexia and fever, or hyperthermia, due to overwhelming bacterial infection.

Vasodilation and increased cardiac output due to sepsis.

Therapy are include :

Restore intravascular volume via I.V fluid

Give supplemental O2 therapy

Identify and control source of infection

Administer antibiotic

Remove risk factor for infection

4. Neurogenic shock (caused by damage to the nervous system) Neurogenic shock is shock caused by the sudden loss of the sympathetic nervous system signals to the smooth muscle in vessel walls. This can result from severe central nervous system (brain and spinal cord) damage. With the sudden loss of background sympathetic stimulation, the vessels suddenly relax resulting in a sudden decrease in peripheral vascular resistance and decreased blood pressure. Signs and symptoms:

similar to hypovolaemic shock except in the skin's characteristics. In neurogenic shock, the skin is warm and dry.

MANAGEMENT

Therapy are include :

Large volumes of fluid may be needed to restore normal hemodynamics Vasopressors (Norepinephrine)

Atropine (speeds up heart rate and Cardiac Output) 5. Anaphylactic Shock (caused by allergic reaction) Anaphylaxis is an severe, whole-body allergic reaction. After an initial exposure to a substance like bee sting toxin, the person's immune system becomes sensitized to that allergen. On a subsequent exposure, an allergic reaction occurs. This reaction is sudden, severe, and involves the whole body. Common causes include insect bites/stings, horse serum (used in some vaccines), food allergies, and drug allergies. Symptoms of anaphylaxis are related to the action

of Immunoglobulin E and other anaphylatoxins, which act to release histamine and other mediator substances from mast cells (degranulation). In addition to other effects, histamine induces vasodilation of arterioles and constriction of bronchioles in the lungs, also known as bronchospasm (constriction of the airways). Symptoms can include the following : Polyuria, respiratory distress, hypotension (low blood pressure), encephalitis, fainting, unconsciousness, urticaria (hives), flushed appearance, angioedema (swelling of the lips, face, neck and throat), tears (due to angioedema and stress), vomiting, itching, diarrhea, abdominal pain, anxiety, impending sense of doom. Therapy are include :

Identify and remove causative antigen Administer counter-mediators such as antihistamine Oxygen therapy and I.V fluid replacement

POSTED BY OCHA AT 8:39 PM 1 COMMENTS:

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