Shock : types and management - PowerPoint Presentation

1. Shock : types and management A.L. Mohammed Kareem

2. 22020-2021Definition: Shock is a life-threatening condition that occurs when the body is not getting enough blood flow(hypoprefusion). Lack of blood flow means the cells and organs do not get enough oxygen and nutrients to function properly. Many organs can be damaged as a result. Shock requires immediate treatment and can get worse very rapidly. As many 1 in 5 people who suffer shock will die from it .Shock

3. 32020-2021Etiology: Adequate tissue perfusion depends on 3 factors:Blood volume.Capacity of the blood vessels. Pumping action of the heart

4. 42020-2021Cells switch from aerobic to anaerobic metabolismlactic acid productionCell function ceases & swellsmembrane becomes more permeableelectrolytes & fluids seep in & out of cellNa+/K+ pump impairedmitochondria damagecell deathPATHOPHYSIOLOGYPATHOPHYSIOLOGY

5. 52020-2021Stages of Shock

6. 62020-2021Hypovolemic shock: Cardiogenic shock: Vasogenic shock: Septic shockNeurogenic shockAnaphylactic shockTypes of Shock

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8. 82020-2021Definition: Cardiogenic shock is a serious condition that occurs when your heart cannot pump enough blood and oxygen to the brain, kidneys, and other vital organs. Cardiogenic shock is considered a medical emergency and should be treated immediately. Cardiogenic Shock

9. 92020-2021Causes MyopathyMechanicalArrhythmic. Cardiogenic shock Myocardial infarction (Left ventricle, Right ventricle) Myocardial contusion (trauma) Myocarditis Cardiac tamponed Septic myocardial depression Pharmacologic cardiotoxicityBradycardia Sinus (e.g.,vagal syncope)Atrioventricular blocksTachycardia Supraventricular , fibrillation VentricularValvular failure Regurgitant Obstructive Hypertropic cardiomyopathy Ventricular septal defect

10. 102020-2021Skin: Pale, Cold, Clammy . the blood circulate to the peripheries.Decreased systolic blood pressure. The systolic blood pressure decreases to 30 mmHg below baseline.Tachycardia. Tachycardia occurs because the heart pumps faster than normal to compensate for the decreased output all over the body.Rapid respirations. The patient experiences rapid, shallow respirations because there is not enough oxygen circulating in the body.Oliguria. An output of less than 20ml/hour is indicative of oliguria.Mental confusion. Insufficient oxygenated blood in the brain could gradually cause mental confusion .Clinical Manifestations

11. 112020-2021Diagnosis of cardiogenic shock may include the following diagnostic tests:Blood pressure measurement. People in shock have very low blood pressure. Electrocardiogram (ECG ). If you have damaged heart muscle or fluid buildup around your heart, the heart won't send electrical signals normally.Chest X-ray. A chest X-ray shows the size and shape of your heart and whether there's fluid in your lungs.Enzyme levels. such as lactic dehydrogenase, creatine kinase. Aspartate aminotransferase and alanine aminotransferase may confirm MI.Echocardiogram. This test can help identify damage from a heart attack.Cardiac catheterization (angiogram). This test can reveal blocked or narrowed arteries. Diagnosis

12. 122020-2021Cardiogenic shock treatment focuses on reducing the damage from lack of oxygen to heart muscle and other organs.Emergency life supportMost people who have cardiogenic shock need extra oxygen. If necessary, you'll be connected to a breathing machine (ventilator). Treatment

13. 132020-2021Fluid therapy. Administration of fluids must be monitored closely to detect signs of fluid overload.. Vasopressors. These medications are used to treat low blood pressure. They include dopamine, epinephrine (Adrenaline), norepinephrine (Levophed) and others.Inotropic agents. These medications, which help improve the pumping function of the heart, They include dobutamine, dopamine and milrinone.blood-thinning medications . usually given immediately to reduce blood clotting and keep blood moving through a narrowed artery, They include Aspirin, Antiplatelet (clopidogrel (Plavix)) and heparinMedications

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15. 152020-2021DEFINITION syndrome characterized by decreased circulation blood volume (hypovolemia), which results in reduction of effective tissue perfusion pressure and generalized cellular dysfunctions. causes • Loss of blood hemorrhage (internal, external). • Loss of plasma burns, Edema, ascites, peritonitis• Loss of fluid severe vomiting & diarrhea. excessive diuretics Hypovolemic Shock:

16. 162020-2021Hypovolemic Shock:

17. 172020-2021• increased serum lactate, • arterial pH, Metabolic laboratory studies • ABO system • fluid and electrolytes • Serial hemoglobin and hematocrit determinations and coagulation panels to assess the need for blood product replacementLABORATORY STUDIES

18. 182020-2021• Pulse : (weak, rapid pulse) thread Weak: due to systolic more than diastolic = small pulse Tachycardia : drénaline sécrétion → stimulâtes SA node (Tachycardia>100b/m)• Blood Pressure: Hypotension. ( VR . cardiac output )• Tachypnea and air hunger > from stimulation of respirator center early increase of RR • Temperature: Hypothermia from metabolism by hypoxia & hypotension. • Skin: Pale, Cold, Clammy • Urine output : Oliguria from renal hypoperfusion + ADH and Aldosterone. • CNS: Vary from anxious to drowsy. Signs

19. 192020-2021Fluids and Blood transfusion: a. Start I.V infusion of 1000-2000 cc of lactated Ringer's solution over the first 45 minutes (at the same time, a blood sample is obtained cross-matching & preparation of blood transfusion). b. Patients with severe blood loss persistent bleeding will show transient improvement and well require blood transfusion or blood substitutes (plasma expanders).Treatment of Hypovolemic Shock

20. 202020-20212 Positioning : The patient should lie supine with elevation of lower limbs → +++ venous return.3. Oxygen : Administration by facial mask, nasal catheter or endotracheal tube. 4. Hydrocortisone I.V : May be givens in patients with adrenal suppression or insufficiency.5. Inotropic agents : (Dopamine) improve myocardial contractility + renal blood flow. 6. I.V Na+ bicarbonate to correct metabolic acidosis. 7. Analgesia -pethidine 50-100mg IV. to anxious patients. Treatment of Hypovolemic Shock

21. 212020-2021Vasogenic shockAnaphylactic Shock

22. 222020-2021Anaphylactic Shock(Vasogenic shock) This type of shock occurs due to Antigen antibody reaction (allergic reaction) leads to release of large amount of histamine which causes capillary paralysis, dilatation and pooling. The best example is penicillin injection in a sensitized patient.

23. 232020-2021Pathophysiology Anaphylactic Shock• Antigen exposure• body stimulated to produce IgE antibodies specific to antigen– drugs, bites, contrast, blood, foods, vaccines• Reexposure to antigen– IgE binds to mast cells and basophils• Anaphylactic response

24. 242020-2021Anaphylactic Response• Vasodilatation• Increased vascular permeability• Bronchoconstriction• Increased mucus production• Increased inflammatory mediators in sites of antigen interaction

25. 252020-2021• Generalized erythema, urticarial, and subsequent angioedema may occur. • Later symptoms may include. Anxiety and restlessness, dyspnea, wheezing, warm feeling, and even pain. • Respiratory manifestations, laryngeal edema, or severe bronchoconstriction ,stridor. • Hypotension from vasodilation Clinical Presentation Anaphylactic Shock

26. 262020-2021maintaining adequate airway and monitoring patient response to the antigen. monitors respirations, heart rate, blood pressure.Give the patient corticosteroid injection .and crystalloid administration antihistaminics Vasopressors Management Anaphylactic Shock

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28. 282020-2021Definition -Septic shock is the end result of numerous complex interactions between several endotoxins, endogenous mediators. • Enodotoxins of Gram-ve bacteria or Candida stimulates macrophages, which stimulates the production of large of inflammatory mediators. In high levels of Enodotoxins as in septicemia→ shock, mediated by cytokines (IL-1, TNF ) resulting in : 1. Systemic peripheral vasodilatation→ pooling of blood & hypotension. 2. Reduced myocardial contractility• Predisposing Factors: • (old age, DM. corticosteroids, chemotherapy, malignancy. Septic Shock (vasogenic shock)

29. 292020-2021Clinical Presentation Septic Shock• Two phases:Hyperdynamic (warm) stage:  Fever (> 38oc) with warm dry skin.  Tachycardia , hypotension & tachypnea . Oliguria.  The cardiac out-put is normal or elevated and If not treated, patient will pass to the next stage.

30. 302020-2021Hypodynamic (cold) stage:  Sever tachycardia , hypotension & tachypnea  Cold clammy skin  Marked oliguria.  Complicated by: 1. Acute erosive gastritis. 2. Systemic inflammatory response syndrome(SIRS) 3. Multiple organ failure (MOF) 4. death.

31. 312020-2021• PHYSICAL FIDINGS -Mental status, increased respiratory rate -compensation for the metabolic acidosis and fever or hypothermia. Because of the exaggerated inflammatory response with release of vasoactive mediators. • LABORATORY STUDIES • Cultures: blood, sputum urine. Surgical or nonsurgical wounds. • CBC: WBCS usually will be elevated and may decrease, with progression of shock. • Sequential multiple_analysisAssessment

32. 322020-20211. Admission into I.C.U. for proper monitoring and 2. Eradicate the source of infection: e.g. gangrenous parts, drainage of intra-abdominal abscess.. etc. 3. Antibiotics: Start with a combination of 3rd generation ( according to culture and sensitivity). 4. Correction of fluid imbalance: by Ringer's lactate + plasma or blood transfusion. 5. Oxygen mask or mechanical ventilation if PO2<60 mmHg6. Indomethacin & corticosteroids I.V.: To antagonize inflammatory mediators 7. Vasopressors and Inotropic. Treatment of Septic Shock

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34. 342020-2021Definition • In neurogenic shock, vasodilation occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation . that is caused by the sudden loss of signals from the sympathetic nervous system that maintain the normal muscle tone in blood vessel walls.Causes Spinal cord injury.Spinal anesthesia.Depressant action of medications. Depressant action of medications and lack of glucose could also cause neurogenic shock.NEUROGENIC SHOCK

35. 352020-2021Disruption of sympathetic nervous systemLoss of sympathetic toneVenous and arterial vasodilationDecreased venous returnDecreased stroke volumeDecreased cardiac outputDecreased cellular oxygen supplyImpaired tissue perfusionImpaired cellular metabolismPathophysiology of Neurogenic Shock

36. 362020-2021The clinical manifestations of neurogenic shock are signs of parasympathetic stimulation.Dry, warm skin. skin due to vasodilation and inability to vasoconstrict . Hypotension. Hypotension occurs due to sudden, massive dilation . Bradycardia. Instead of getting tachycardic, the patient experience bradycardia . Respiratory arrest. If the injury is above the 3rd cervical vertebra, the patient will go into respiratory arrest immediately following the injury, due to loss of nervous control of the diaphragm.Clinical Manifestations

37. 372020-2021• The patient should lie flat, elevation of the legs help to increase venous return. • Supplement 02 .• IV Crystalloids like Ringer's lactate. • Vasopressor drugs.Treatment of Neurogenic Shock

38. 382020-2021THANK YOU