Shock and Management

Dr. Sudhir K.JainProf Surgery

MAMC

Shock and Management:Presented By:Dr. Sudhir. K. Jain, M.S, MBA(HCA), FRCS, FICS, FIAS.

Professor of Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi.

With Credits to:Dr. Vishnuraja, PG2, Dept of Surgery, MAMC.Dr. Ronal Kori, PG2, Dept of Surgery, MAMC.

Shock-(Noun)-Oxford English Dictionary1. Sudden upsetting or surprising event or experience2. Feeling of disturbed surprise resulting from a sudden upsetting event3. A disturbance causing instability in an economy4. Short form for Electric shock5. A violent shaking movement caused by an impact, explosion or

tremor6. An acute medical condition associated with fall of BP caused by

events such as loss of blood, burns, allergic reactions or sudden emotional stress.

ShockAcute clinical state characterized by inadequate cellular perfusion leading to cellular damage and failure of major organ systems.Basic pathology is inadequate (Not always low) cardiac output for the metabolic needs of the tissue.

Shock-CausesCardiogenic (Pump failure)• Eg. M.I, Cardiac contusion, tension pneumothorax, cardiac

tamponade, pulmonary embolus.

Peripheral failure of venous return:• True hypovolemia: Loss of blood (Ext or int hemorrhage), loss of

plasma (Burns), loss of ECF volume• Pooling of blood (Apparent hypovolemia): Neurogenic (Spinal injury,

vasovagal attack), Anaphylactic (Ag/Ab reaction-drug allergy), Sepsis (Endotoxic shock)

Signs and Symptoms• Restless, anxious, confused and thirsty• Cold sweating• Cyanosed with a rapid feeble pulse• Hypotensive• Low urine output• Hyperventilating

Signs-Contd• CVP decreased (But in Cardiogenic shock patient have increased CVP)• Heart rate increased, but in cardiogenic shock, HR is normal or

decreased• PAW(v)P decreased in hypovolemic shock but increased in cardiogenic

shock• Cardiac output decreased but in early stages of septicemic shock. It

can be increased due to hyperdynamic circulation.

General Measures:• Maintain ABC-Airway, Breathing and Circulation• Airway maintainance:• Remove any debris, foreign body from oral cavity, throat.• Prevent tongue from falling backward by chin lift/Jaw thrust• If patient not able to maintain airway consider

intubation/tracheostomy.

Maintain Breathing:• Give 100% oxygen• Breathing effort inadequate• Artificial respiration• -Mouth to mouth breathing• -Respiratory bag after intubation• -Mechanical ventilator

Maintain Circulation:• Control obvious haemorrhage• Insert two large bore IV cannula• Take blood for grouping, cross

matching• Start IV infusion

-Normal saline/Ringer lactate-Plantar expanders-Dextran 70, Haemacel, Hydroxyethyl starch.-Whole blood in moderate to severe blood loss to maintain Hb >10 gms% and hematocrit >30%.

Haemorrhage-Classification• Depending upon nature of blood vessels• Arterial:

Bright red colour. It jets out, pulsatile.Pulsation of artery can be seen.Can be easily controlled as vessel is visible

• Venous:Dark red in colour.Non pulsatile, never jets out but oozes

out.Difficult to control as vein gets retracted.

• Capillary: Red colour, slow ooze.

Haemorrhage-ClassificationDepending upon time of haemorrhage:1. Primary: at the time of surgery2. Reactionary: 6-12 hr after surgery• Cause: Hypertension in post op period, sneezing, coughing,

retching.3. Secondary: 5-7 days after surgery. • Cause:Due to infection- Sloughing of vessel wall.

Haemorrhage-ClassificationDepending upon duration of haemorrhage:1. Acute haemorrhage: Occurs suddenly eg. Oesophageal varices

bleed2. Chronic haemorrhage: Slow blood over long period eg. Piles,

Chronic duodenal bleedDepending upon nature of bleeding:3. External or revealed haemorrhage Eg.Epistaxis, haematemesis4. Internal or concealed haemorrhage. Eg. Splenic rupture, Rupture

ectopic pregnancy.

Stages of Haemorrhage:• Mild haemorrhage (Class I) <15% of blood loss (<750 cc in 70 kg man)• Moderate (Class II) 15-30% of blood loss. Tachycardia >100. BP- Normal

or slightly increased. Anxious patient. Respiratory rate increased 20-30. Urine output decreased 20-30 ml/hr.• Severe (Class III) 30-40% of blood loss. HR>120 mt. BP-Decreased.

Respiratory rate increased 30-40/mt. Urine output 5-15 ml/hr. Anxious patient, confused.• Class VI: >40%. Patient confused and lethargics, No urine output. RR >35• 50% loss of blood volume: Patient unconscious, BP not recordable,

Peripheral pulses not

Treatment:• Upto one litre < 20% of blood volume

Use of blood as replacement not required.Crystalloids alone or crystalloids and colloid (2:1) are transfused.If crystalloids alone used-3/4 times the blood loss volume need to be transfused because crystalloids go into whole ECF compartment.

• 1-2 litres of blood loss (20-40%)1 litre crystalloid (NCL 0.9%) (30-60/mt)1 litre colloid (Dextran or haemacel)2 redcell concentrate to restore oxygen carrying capacity.

• > 40%Whole blood transfusion.4.5% albumin infusion.

Haemorrhage Control-Local methods• Pressure and packing• Position and rest. Eg. Limb elevation• Tourniquets- Pneumatic, Rubber bandage• Contraindication- Venous haemorrhage, Pt with peripheral vascular

disease

Haemorrhage control-Surgical Methods• Artery forceps• Ligature• Cautery• Clips

Spectrum of Infections:There exists a spectrum of disease starting with bacteria leading to Septic Shock and MODS• Bacteremia: Presence of bacteria in the blood (Can be natural during

straining/defaecation)• Septicemia: Presence of microbes or toxins in blood (Pathological)• SIRS: Systemic inflammatory response syndrome:

Diagnostic Criteria: if two or more of the following present.

SIRS: Diagnostic CriteriaTwo or more of the following:• Temperature >38 degree or <36 degree• Heart rate > 90/min• Respiratory rate > 20/min or partial pressure of carbon dioxide in

arterial blood PaCO2 of less than 32 mm Hg.• Leukocytosis (WBC > 12000/mm3) or Leukopenia (WBC <4000/mm3)

Spectrum of Septic Shock:• Sepsis: Confirmed infection and atleast two SIRS criteria• Severe sepsis: Sepsis and organ dysfunction as evidenced by arterial

hypoxemia, lactic acidosis, oliguria, altered mental status and so on.

• Septic Shock: Sepsis and hypotension refractory to fluid resuscitation

Septic shock: Mechanism• Nitric oxide and Prostacyclin and inflammatory

mediators produced during Septic shock cause Vasodilation, leads to hypoperfusion

• Inflammatory mediators also cause Capillary thrombosis, leukocyte plugging of Capillaries.

• Tissue hypoperfusion, Capillary thrombosis and leukocyte plugging in organs leads to ORGAN FAILURE

Septic Shock-Treatment• Antibiotics- to control infection• Removal of Source of infection- Eg: Abscess drainage, Removal of

infected catheters etc.• Hemodynamic, metabolic and respiratory support.

Septic Shock-Goal directed Therapy:Goals: 1. Mean arterial pressure > 65 mm Hg2. Saturation of Central venous oxygen (ScvO2

>70%)

Method:Give CVP guided fluidsIf MAP less than 65 mm Hg, Start IonotropesIf MAP more than 65 mm Hg, look for ScvO2

If ScvO2 less than 70%, Start IonotropesIf ScvO2 more than 70%, Observe

Thank You