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“A rude unhinging
of the machinery of
life”
- Gross -: RAJAN
Definition
Shock is a systemic state of low
tissue perfusion, which is
inadequate for normal cellular
respiration. With insufficient
delivery of oxygen and glucose,
cells switch from aerobic to
anaerobic metabolism. If
perfusion is not restored in a
timely fashion, cell death ensues.
Pathophysiology
Physiologic response to hypovolemia
directed at preservation of
perfusion to vital organs
Tissue oedema
Cellular hypoxia
Systemic
Cardiovascular
in preload & afterload
Sympathetic activity
Central chemoreceptors
– Medulla (associated with
cardiovascular control “centers”)
Contd.
Increasingly important when mean
arterial pressure falls below 60
mmHg (i.e., when arterial
baroreceptor firing rate is at
minimum)
Acidosis resulting from decreased
organ perfusion stimulates central
and peripheral chemoreceptors →
sympathetic activation
Stagnant hypoxia in carotid bodies
enhances peripheral vasoconstriction
Respiratory
R.Rate & MV
(excretion of Co2)
Compensatory respiratory
alkalosis
Renal
Endocrine
Vasopressin (ADH) released from
hypothalamus in response to
preload vasoconstriction &
reabsorption of water in collecting
system.
Hypothalamus
CRH
ACTH
Cortisol
Endothelial injury(lungs,kidney)
Ischaemia-reperfusion
syndrome
Cardiogenic
Obstructive
Distributive
Endocrine
Types
Hypovolaemic shock
-Due to reduced circulating volume.
3. Haemorrhagic
4. Non-Haemorrhagic
Causes of non-haemorrhagic shock
-Dehydration,
diarrhoea,vomiting,evaporation,3rd
space loss, bowel obstruction or
pancreatitis.
Types
Cardiogenic shock
Primary failure of the heart to pump.
Causes
-MI, cardiac dysrhytmias, valvular
heart disease,blunt myocardial
injury,cardiomyopathy.
-d/t endogenous factors (in sepsis)
-d/t exogenous factors (drugs)
Types
Obstructive shock
Reduction in preload due to
mechanical obstruction of
cardiac filling.
Causes
Distributive shock
Inadequate organ perfusion
accompanied by
3. Vascular dilatation with
hypotension
4. Low SVR
5. Inadequate afterload
6. Abnormally high cardiac output
Types
Causes
-Septic shock
-Anaphylaxis
-Spinal cord injury
Types
Endocrine shock
Combination of hypovolaemic,
cardiogenic & distributive shock.
Causes
Mild shock
Moderate shock
Severe shock
Clinical features
compensa mild moderat severe
ted e
Lactic + ++ ++ +++
acidosis
UOP normal normal oliguric Anuric
Level of Normal Mild drowsy Comat
consciou anxiety ose
sness
R.Rate Normal Increased Increase Labour
d ed
Pulse Mild increased increase increas
increase d ed
B.P. normal normal Mild low Severe
low
Clinical Markers
Brachial systolic blood
pressure: <110mmHg
Sinus tachycardia: >90
beats/min
Respiratory rate: <7 or >29
breaths/min
Urine Output: <0.5cc/kg/hr
Metabolic acidemia:
Contd.
Tachycardia
- Not always accompany shock
- Who on β-blocker or have implanted
pacemakers unable to mount
tachycardia
- A pulse rate of 80 in a fit young adult
who normally has a pulse of 50 is
abnormal
Contd.
Blood pressure
- Hypotension is one of the last sign
- Children & fit young adults are able
to maintain B.P. until the final stages
(compensatory mechanism lead to
in SV & peripheral vasoconstriction)
- Elderly hypertensive pts may present
with ‘normal’ BP but be hypovolemic
& hypotensive
-
Consequences
Unresuscitable shock
- Profound shock for a prolonged
period of time
- Cell death follows from cellular
ischemia
- Ability to compensate lost
- Myocardial depression
- Non responsive to fluid or ionotropes
- Peripherally loss of ability to maintain
SVR
Contd.
Conduct of resuscitation
- Should not be delayed
- Timing & nature of resuscitation
depend on type of shock and timing
& severity of insult
- Rapid examination to make a
diagnosis & detect the source
- If there is doubt about cause it is
safer to assume the cause is
hypovolemia. Begin with fluid
Contd.
Fluid therapy
- Hypovolemia & inadequate preload
must be addressed 1st
- First-line therapy is IV access and
administration of IV fluids
- Short wide bore catheters preferred
- Central venous catheters are more
appropriate for monitoring
Contd.
Type of fluid
- There is no ideal resuscitation fluid
- It is more important to understand
how & when to administer them
- Crystalloid vs Colloid
- Their O2 carrying capacity zero
- Blood should be replaced with blood
- Hypotonic solution like dextrose
should not be used unless the deficit
is free water loss(DI) or Na+ overload
Contd.
Cardiac output
- Asseses
3. Cardiac function
4. Systemic vascular resistance
5. Preload (end-diastolic volume)
6. Blood volume
Systemic & organ
perfusion
Goal of t/t is to restore cellular &
organ perfusion
UOP is the best monitor
Level of consciousness – marker of
cerebral perfusion
Clinical indicators of perfusion of GIT
& muscular beds are lactate & base
deficit and the mixed venous oxygen
saturation
Clinical Investigationa
l
System Base deficit; lactate;
ic mixed venous O2 sat.
perfusi
Organ
on
perfusi
on
Muscle - Near infrared
spectroscopy
Gut - Sublingual
capnometry;p
H;flowmetry
Kidney UOP -
Brain Level of consciousness Near infrared
spectroscopy
Base deficit and lactate
>70% in sepsis
Disordered utilisation of O2 at
cellular level
Arteriovenous shunting of blood
Rapid correction required with
- Fluid therapy
- Inotropes
Endpoints of
resuscitation
Resuscitation complete when
oxygen debt repaid,tissue acidosis
corrected & aerobic metabolism
restored
Systemic Parameters
Lactate
Base deficit
Tissue Parameters
Gastric tonometery
Sepsis in a
surgical patient
Shock associated with sepsis is
found to be major cause of death
in surgical intensive care
Cause of this is
- widespread use of
antimicrobials, steroids,
indwelling catheters &
What is sepsis?
Sepsis can be response to any class
of micro organism that may spread
beyond invaded tissue
Septic insult
Complement activation Macrophage activation
TNF, IL – 1,6
Neutrophil Endothelial cell
activation Up regulation
Arachidonic
bradykinin coagulation metabolites
N2O Oxygen radicals
Tissue
Capillary leak microthrombosis vasodilation vasodilation
destruction
Organ injury
Complications of sepsis
Cardiopulmonary – ARDS, arteriolar
vasodilatation, myocardial
dysfunction
Coagulation – thrombocytopenia,
disseminated intravascular
coagulation
Initial Resuscitation