Presentation on theme: "SHOCK Abdul.Kader WEISS M.D"— Presentation transcript:
1SHOCK Abdul.Kader WEISS M.D CHIRURGIE GENERALE ET VISCERALE /CHIRURGIE COELIOSCOPIQUED.E.S , A.F.S ,A.F.S.A , DU / FRANCEReference :Editors: Pierce A. GraceNeil R. Borley / Title: Surgery at a Glance 2edBlackwell ScienceEditors : Seymour i. Schwartz, M.D. / Title :Principles of Surgery Companion HandbookMcGraw-Hill Companies, Inc
2SHOCKSHOCK IS A PATHOPHYSIOLOGIC CONDITION CLINICALLY RECOGNIZED AS A STATE OF INADEQUATE TISSUE PERFUSION.THERE ARE FOUR DISTINCT CATEGORIES:HEMATOGENICNEUROGENICVASOGENICCARDIOGENICIt is clear that shock is a SYSTEMIC DISORDER that disrupts vital organ function as the eventual result of a variety of causes.Whereas hemorrhagic or traumatic shock is characterized by global hypoperfusion, septic shock may be associated with hyperdynamic circulation resulting in a maldistribution of regional or intraorgan blood flow.
3KEY POINTS Identify the cause early and begin treatment quickly. Shock in surgical patients is often over looked-unwell, confused, restless patients may well be shocked.Unless a cardiogenic cause is obvious, treat shock with urgent fluid resuscitation.Worsening clinical status despite adequate volume replacement suggests the need for intensive care.
5PATHOPHYSIOLOGYMany conditions can lead to an inadequate delivery of oxygen to vital structures of the body.An aide-mémoire can be categorised as :● Decrease in oxygen uptake by the lungs● Reduced venous return● Impaired cardiac function● Reduced arterial tone● Impaired organ autoregulation● Decreased oxygen uptake and utilisation by tissues
7HYPOVOLAEMIC SHOCK TRUE LOSS COMMON EXAMPLES BLOOD LOSS GASTROINTESTINAL HAEMORRHAGERUPTURED AORTIC ANEURYSMTRAUMAPLASMA LOSSDIARRHOEA AND VOMITINGDIABETIC KETOACIDOSISPANCREATITISOSMOTIC DIURESISHYPONATRAEMIABURNSFISTULA AND OSTOMIESAPPARENT LOSSVENODILATORSNITRATES, OPIATES, I.V LOOP DIURETICSGLUCOCORTICOID DEFICIENCY
9ANAPHYLACTIC SHOCKAnaphylaxis is an acute reaction to a foreign substance to which the patient has already been sensitised.This leads to an immunoglobulin E (IgE) triggered rapid degranulation of mast cells and basophils .Anaphylactoid reactions have an identical clinical presentation but are not triggered by IgE and do not necessarily require previous exposure.Furthermore, they may not produce a reaction every time.
10COMMON CAUSES OF ANAPHYLAXIS/ANAPHYLACTOID REACTIONS DRUGS (PROTEIN AND NON-PROTEIN) – COMMONLY PENICILLIN OROTHER Β LACTAM DRUGS, BLOOD PRODUCTS, AND IMMUNOGLOBULINSVACCINESFOOD – ESPECIALLY NUTS, SHELLFISHVENOMS – ESPECIALLY BEES, WASPS, AND HORNETSPARASITESCHEMICALSLATEXANAPHYLACTOIDCOMPLEMENT ACTIVATIONCOAGULATION/FIBRINOLYSIS SYSTEM ACTIVATIONDIRECT PHARMACOLOGICAL RELEASE OF MEDIATORSEXERCISE INDUCEDIDIOPATHIC
11TOXIC OR SEPTIC SHOCK Gram –ve or, less often, Gram +ve infections. Retained tamponAbscessEmpyemaSurgical wound infectionOsteomyelitisCellulitisInfected burnsSeptic abortion
12NEUROGENIC SHOCKA spinal lesion above T6 can impair the sympathetic nervous system outflow from the cord below this level.As a consequence both the reflex tachycardia and vasoconstriction responses to hypovolaemia are eliminated.The result is generalised vasodilatation, bradycardia and loss of temperature controlAs neurogenic shock leads to a reduction in blood supply to the spinal column, it gives rise to additional nervous tissue damage.
13CLINICAL FEATURES HYPOVOLAEMIC AND CARDIOGENIC SEPTIC Pallor, coldness, sweating and restlessness.Tachycardia, weak pulse, low BP and oliguria.SEPTICInitially warm, flushed skin and bounding pulse.Later confusion and low output picture.
14INVESTIGATIONS AND ASSESSMENT Monitor pulse, BP, temperature, respiratory rate and urinary output.Establish good i.v. access and set up CVP line (possibly Swan–Ganz catheter as well).ECG, cardiac enzymes, echocardiography.Hb, Hct, U+E, creatinine.Group and crossmatch blood: haemorrhage.Blood cultures: sepsis.Arterial blood gases.
15COMPLICATIONS• ‘SIRS’ (systemic inflammatory response syndrome) may ensue if shock not corrected. • Acute renal failure (acute tubular necrosis). • Hepatic failure. • Stress ulceration.
16SIRS (SYSTEMIC INFLAMMATORY RESPONSE SYNDROME) SIRS (systemic inflammatory response syndrome) is a systemic inflammatory response characterized by the presence of two or more of the following:• hyperthermia >38°C or hypothermia <36°C• tachycardia >90 bpm• tachypnoea >20 r.p.m. or PaCO2 <4.3 kPa• neutrophilia >12 × 10*9 l–1 or neutropenia <4 × 10*9 l–1.Sepsis syndrome is a state of SIRS with proven infection.Septic shock is sepsis with systemic shock.
17ESSENTIAL MANAGEMENT • AIRWAY & BREATHING: • CIRCULATION: Give 100% O2, sit up, consider ventilatory support if necessary.• CIRCULATION:Ensure good IV access, urinary catheter, monitor cardiac rate and rhythm.
18DEAL WITH THE CAUSE OF THE SHOCK ESSENTIAL MANAGEMENTDEAL WITH THE CAUSE OF THE SHOCK( e.g. stop the bleeding, drain the abscess, remove the source of the anaphylactic antigen, etc.).