prezentace aplikace powerpoint · prezentace aplikace powerpoint author: lf uk created date:...
TRANSCRIPT
Shock
B. Mladosievicova
Definition
State of acute generalized circulatory failure causing inadequate tissue perfusion
The effects of shock are initially reversible,
but rapidly become irreversible, resulting
in multiorgan failure (MOF) and death
Shock left untreated may be
fatal.
It must be recognized and
treated immediately
Shock at cellular level
• oxygen delivery to the cells is not sufficient to sustain cellular activity
• the central role of microcirculation in providing oxygen to the cells
Microcirculatory dysfunction leads to
• dysfunction of cell membranes, breakdown of cellular metabolism
• Reduced oxygen and nutrients delivery in cells – LA – decreased cellular pH- release of strong enzymes, RMO – loss of cell integrity – loss of cells in brain, heart– irreversibility of shock
Finfer SR,
NEJM 2013
Activating hematologic system
Activating CVS
Activating renal system
5/11/2017 10
Hypovolemic Shock
Hemorrhagic/Traumatic
Blood (external, internal)
Fluid (GIT,kidneys...)
Plasma - burn
increased: Hb, Ht, plasma proteins -
from haemoconcentration
The most common causes of HS
External blood loss: penetrating trauma, GI bleeding disorders
Internal blood loss: organ injury, abd. aortic aneurysma
Hypovolemic shock -phases
• Compensation (latent)
• Decompensation
• Irreversible
Compensatory period able to compensate blood loss to 20%
• Releasing of catecholamines
• Constriction of arteriols and veins, shift of blood to arterial region
• Centralisation of blood to heart and brain from splanchnic tissues, skin, kidneys (activation of RAAS – retention of Na, water, increased osmolality, releasing of ADH - oliguria), decreased HP, higher oncotic pressure in capillaries
Hypoperfusion – ischemic triggers releasing of
TNF-alpha, IL-1,IL-2,IL-6,IL-8. Metabolites of arachidonic acids,
lysosomal ee,, vasoactive mediators (k, h, s)
Decompensation
• If centralisation longer than 1-2 hours
• If blood loss is more than 20-30%
• METABOLIC FAILURE OF CELLS - MA
Blood loss BP(mmHg) Heart rate (bpm) Diuresis 10-15% normal normal normal
15-30% <100 > 100 oliguria
30-40% < 90 > 120 anuria
Shock starts when
systolic BP<100 and heart rate >100
Hypovolemic = decreased circulating volume
hypotension (rapid 25% volume loss)
rapid pulse (measurable on a. radialis means 90 SBP,
only on a.carotis 70 SBP)
Compression of nail (more than 5 s – means
hypoperfusion)
tachypnea
anxiety
irritability
• reduced level of consciousness - apathy
- coma
• oliguria - urine production less than 400ml/d
• cool skin, pale, thirst, hypothermia
Blood loss
• Closed femoral fracture 300-2000 mL
• Closed costal fracture 150 mL pre each
• Closed fracture of tibie 500 mL
• Open wound 10x10 cm 500 mL
• Haemothorax 2000mL
• State of circulation is modified by fear, cold, pain!!!
Cardiogenic shock
is a life-threatening condition that occurs in
response to reduced cardiac output in the
presence of adequate intravascular volume
and results in tissue hypoxia
Cardiogenic shock
hypoperfusion is usually associated with
increased central venous pressure,
hepatomegaly can be clinically apparent
CARDIOGENIC SHOCK - MI (7% of pts),
heart failure,
arrhythmias
Decreased contractility- reduced cardiac output –
decreased coronary perfusion- further ischemia- necrosis
SBP <90 mm Hg persistent more than 30 min.
urine output < 20 ml/HOUR
peripheral vasoconstriction – oliguria, cool ext.,pale skin...
impaired mental status
ECG, invasive haemodyn. monitoring
Spiral of cardiogenic shock
Management of PTS with cardiogenic shock
- improving myocardial contractility (inotropy –
dopamine…)
- decreasing afterload (vasodilators)
- increasing myocardial oxygen supply
- decreasing “ “ demand
- correcting hypoxia, met. acidosis
- diuretics
- mechanical assist devices – intraaortic ballon pump
reduction of pain, anxiety
5/11/2017 12
Obstructive Shock
Massive pulmonary
Embolism
Cardiac Tamponade
Dissecting of aorta or
aneurysma
Aortic stenosis
11/24/2016 11
Distributive Shock
caused by loss of vasomotor controlvolume remains unchaged, vascular bed
enlarges, CO is high
Septic (mainly – LPS of G negative bact. -
peritonitis, abscess, pneumonia) ATB
Anaphylactic (massive Ag-Ab reactions
no more than 1-2 hours after exposure)
EPINEPHRIN
Neurogenic (sympathetic tone loss –
vasodilation- decreased venous return –
hypotension, bradycardia) ATROPINE
S SEPTIC SHOCK
M (sepsis + hypotension)
- SEPSIS -
systemic inflammatory response syndrome (SIRS)
induced by infection – old definition
Sepsis should be defined as life-threatening organ
dysfunction caused by a dysregulated host response to
infection. For clinical operationalization, organ dysfunction
can be represented by an increase in the Sequential [Sepsis-
related] Organ Failure Assessment (SOFA) score of 2
points or more, which is associated with an in-hospital
mortality greater than 10%.
•
Septic shock
• a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.
• trauma, surgical pts
• DM
• malignancies (+ immunosupressive therapy)
• cirrhosis
• urinary tract, GI infections
• newborns
• in the elderly
SIRS (at least 2 signs)
• > 38°C or <36°C
• tachycardia > 90 bpm
• tachypnoe > 20/min or PaCO2 < 4.3 kPa
• Le > 12 x 109/l or < 4 x 109/l
Infectious Noninfectious
bacterial diabetic complications cholecystitis pneumonia urogenital meningitis etc.
acute intestinal ischemia pancreatitis autoimunne diseases burns aspiration drug reactions cocain/amphetamine MI
Causes of SIRS
Septic shock develops in less than one half of patients with bacteremia. It occurs in about 40% of those patients with gramnegative bacteremia and about 20% of patients with Staphylococcus aureus bacteremia.
Septic shock
• Fever
• Chills
• Sweating
• Altered mental status
- Anxiety
- Agitation
• Head and neck infections - earache, sore throat, sinus pain or congestion, nasal congestion or exudate, swollen
lymph glands • Chest and pulmonary infections - cough (productive),
pleuritic chest pain, dyspnea
• Abdominal and GI infections - abdominal pain, nausea, vomiting, diarrhea • Pelvic and genitourinary infections - pelvic or flank pain,
vaginal or urethral discharge, dysuria, frequency, urgency • Bone and soft tissue infections - focal pain or tenderness,
focal erythema, edema
Management of pts with clinical
signs and symptoms
Ventilation Infusion Pump function
COMPLICATIONS OF SHOCK
IF PERFUSION PRESSURE IS < 50 mm Hg
BRAIN DEATH
FOCAL MYOCARDIAL NECROSIS, HF
CONGESTION OF SPLEEN
STRESS ULCERS IN STOMACH
VASODILATION AND SPLANCHNIC POOLING
NECROSIS OF INTESTINE
ACUTE TUBULAR NECROSIS OF KIDNEY
NECROSIS OF LIVER
ADULT RESPIRATORY DISTRESS SYNDROME (ARDS)
FEVER
Practice questions
What is the first sign of a shock?
What is the most common type of shock in
ICU?
Syncope
• a transient, self-limited loss of consciousness [with an inability to maintain postural tone that is followed by spontaneous recovery.
• It excludes seizures, coma, shock, or other states of altered consciousness.
• Most causes of syncope are benign • In a small subset - several serious heart
conditions, such as bradycardia, tachycardia or blood flow obstruction (e.g. valvular defect), can also cause syncope
50% of the population may experience
a syncopal event during their lifetime
Syncope (fainting)
rapid drop in blood pressure or heart rate
Prior syncope symptoms
• faintness, dizziness, or light-headedness, vertigo, weakness, diaphoresis, epigastric discomfort, nausea, blurred or faded vision, pallor, or paresthesias
• Red flag symptoms - Exertional onset, chest pain, dyspnea, low back pain, palpitations, headache focal neurologic deficits, diplopia, ataxia, or dysarthria
Treatment
depends on the cause or precipitant of the syncope: • Situational syncope – neurally mediated – vasovagal -
patient education regarding the condition • Orthostatic syncope - Patient education;,
mineralocorticoids, and other drugs (eg, midodrine); elimination of drugs associated with hypotension; intentional oral fluid consumptionadditional therapy in the form of thromboembolic disease (TED) stockings
• Cardiac arrhythmic syncope - Antiarrhythmic drugs or pacemaker placement
• Cardiac mechanical syncope – if valvular disease is present, surgical correction
Hypotension (< 100/60)
Cardiac (Low Output) Vascular origins
Arrhythmias
Structural
Disease
Hypovolemia
Systemic
Vasodilation
Obstructive
• pulmonary
embolism
• bradycardia
• tachycardia
• fibrillation
• valvular disease
• ischemic heart disease
• pericardial disease
• cardiac tamponade
• congenital disease
• obstructive
cardiomyopathy
• dilated cardiomyopathy
• primary pulmonary
• hypertension
• hemorrhage
• diarrhea
• dehydration
• orthostatic
volume shifts
• drugs (diuretics)
• sepsis
• anaphylaxis
• neurogenic
• autonomic dysfunction
• drugs