02 shock

Shock
Dr.Indubala Maurya MD,DNB
Assistant Professor
Dept of Aanesthesia & Critical Care
MGMCRI

Introduction
 Shock can be defined as a state of inadequate
or inappropriate tissue perfusion resulting in
abnormal cellular metabolism.
 Shock is associated with anaerobic metabolism,
oxygen debt and tissue acidosis.

 Combination of hemodynamic parameters:
 MAP< 60
 SBP<90
 Clinical feature
 Abnormal lab value ( lactate > 4 mmol/L)

Types of shock
 Hypovolemic shock
 Distributive Shock
 Cardiogenic Shock

Hypovolemic shock
 Hypovolemic shock is related to decreased intravascular
volume, secondary to loss of:
 Blood (e.g. trauma)---- > Hemorrhagic shock
 Plasma (e.g. burns)
 Water and electrolytes (e.g. vomiting, diarrhoea).

Hypovolemic shock
 Clinical feature :

Hypovolemic shock
Management :
 Establish vascular access ; large bore cannula , Send
sample for Hb
 Start fluid resuscitation depending on clinical
presentation -----with crystalloid/Blood product
 Hb > 9gm% ----> continue Fluid therapy
 Hb < 9gm% --- > PRBC, correct coagulation abnormality
 Search for source of bleeding : compression of visible
vascular injury, exposure and control of internal bleeding,
embolisation ,banding

Measure CVP and MAP
 CVP < 8 --------> continue Fluid therapy
 CVP > 8 and MAP < 60 -----> Administer Vasopressor ( NE,DA)
 CVP > 8 and MAP > 60 ------> Resuscitation complete
 Others
 Airway control
 Plt/FFP
 Activated factor VII
 Calcium/magnesium supplement
 Rewarming
 Antibiotics
 look for other cause of shock

Distributive shock
e.g.
 Septic shock
 Anaphylactic shock

Septic shock
Surviving sepsis campaign 2012
Sepsis is defined as the presence of infection together with systemic
manifestations of infection.
Severe sepsis is defined as sepsis plus sepsis-induced organ
dysfunction or tissue hypo perfusion.
Sepsis-induced hypotension is defined as a systolic blood pressure
(SBP) < 90 mm Hg or mean arterial pressure (MAP) < 70 mm Hg or a SBP
decrease > 40 mm Hg or less than two standard deviations below normal
for age in the absence of other causes of hypotension

Septic shock
SBP< 90
MAP < 70
Feature of severe sepsis :
 Fever Hypothermia ,tachy,Tachypnea,Altered mental
status, Leukocytosis ,Leukopenia.
 With one or more organ involvement ( lung ,liver ,kidney )

Septic shock
Management
Goals during the first 6 hrs of resuscitation:
a) Central venous pressure 8–12 mm Hg
b) Mean arterial pressure (MAP) ≥ 65 mm Hg
c) Urine output ≥ 0.5 mL/kg/hr
d) Central venous (superior vena cava) or mixed venous
oxygen saturation 70% or 65%, respectively

 CVP < 8  continue fluid resuscitation
 CVP > 8
MAP < 65  add vasopressure
MAP > 65
 ScvO2 < 70 %
 Add dobutamine
 Transfuse if Hb < 7
 ScvO2 > 70 %  achieved all goals

•Fluid Therapy of Severe Sepsis:
• Crystalloids as the initial fluid of choice in the resuscitation
•Vasopressors
• Norepinephrine as the first choice vasopressor
•Inotropic Therapy
• Dobutamine infusion
• myocardial dysfunction as suggested by elevated cardiac
filling pressures and low cardiac output.
• ongoing signs of hypoperfusion, despite achieving adequate
intravascular volume and adequate MAP
•Blood Product Administration
• Red blood cell transfusion if Hb <7.0 g/dL
• Platelets prophylactically when counts are <10,000/mm3 in the
absence of apparent bleeding

Diagnosis :
• Cultures as clinically appropriate before antimicrobial therapy
• imaging
•Antimicrobial Therapy
• Administration of effective broad spectrum intravenous
antimicrobials within the first hour of recognition of septic shock.
• Not more than 5 days, De-escalate antibiotic therapy.
• Duration of therapy typically 7–10 days
•Source Control
• eg: abscess drainage
•Mechanical Ventilation of Sepsis-Induced ARDS

Anaphylactic shock
 Anaphylaxis :
 life threating clinical manifestation
 IgE mediated hypersensitivity
 Mast cell and basophil degranulation
 Anphylactoid rxn:
 Not IgE mediated

Anaphylactic shock
 Causes
 Anaphylaxis :
 Food( Nuts,egg etc)
 Antibiotics,vaccines blood n blood products,latex
 Anaphylactoid rxn
 NSAID
 Opiates
 Gamma globulin
 antisera

Anaphylactic shock
 Clinical manifestations :
 Eyes: conjuctival erthyrema, periorbital odema
 Skin: pruritus flushing urticaria angioedema
 CVS: hypotension, Tachy (Brady if severe), cardiac
arrest
 Resp: Dyspnea,wheezing,pulmonary odema
 GIT : Nausea/vomiting,Diarrohea, Abdo pain

Anaphylactic shock
 Suspected impending respiratory collapse ---->
intubate
 IM epinephrine 0.3-0.5 mg to ant/ lat thigh
 For severe symptoms poor response
 Iv bolus epinephrine 0.1-0.2 mg
 If hypotensive start fliud therapy
 if no response to above
 start iv epi infusion
 Aggressive fluid therapy
 Pt on beta blocker ----> Glucagon

 Treat all patients with Histamine 1,2 blocker
Diphenhydramine (H1)
Ranitidine (H2)

Cardiogenic shock
 Cardiogenic shock is related to ‘pump’
failure from many possible causes
 myocardial infarct ( common)
 valve dysfunction
 papillae rupture
 arrhythmias
 tamponade
 pulmonary embolus

Cardiogenic shock
SBP< 90
Sign of low cardiac output ( oliguria,poor
mental status , pulmonary odema )
 Adequate intravascular volume ( PAOP > 15
mmhg)

Cardiogenic shock
 Initial evaluation & rapid stabilization
 Immediate ECG:
 Look for evidence of AMI (ST ele , LBBB)
 Supplemental O2/mech vent
 BP support
 Dopamine
 Nor epi
Need CVP,Intra arterial blood pressure monitoring

Cardiogenic shock
 Patient with positive ECG finding :
 Immediate reperfusion therapy :
 Thrombolytic therapy
 Cardiac catheterization
 Negative ECG finding :
 Rule out mechanical cause of CS ( ECHO)
 Cardiac monitoring ( confirm cardiac etiology )
 Continued medical support (vasopressure, inotropic)

Cardiogenic shock
 In case of refractory cardiac shock
 Left venticular assist device
 Transplant
 Cradiac temponade :
 Beck’s triad ( raised jvp,muffled hreart sound,hypotension)
 Presence of pulsus paradox( insp fall in SBP>10)
 Echo finding
 Consider Subxiphoid Pericardiocentesis

02 shock

More Related Content

What's hot (20)

Similar to 02 shock (20)

More from anaesthesiology-mgmcri (20)

Recently uploaded (20)

02 shock

Editor's Notes