1. Shock Presented by Dr Azza Serry

2. Learning objectives  Definition  Pathophysiology  Types of shock  Stages of shock  Clinical presentation  management

3. Types of shock Shock Shock is inadequate tissue perfusion leading to decreased oxygen delivery to tissues. types  Hypovolaemic  Cardiogenic  Obstructive  Distributive

4. Hypovolae mic shock  Hypovolaemic shock  Tissue hypoperfusion resulting from inadequate intravascular volume.  Caused by reduced circulatory volume due to haemorrhage or fluid loss.  Haemorrhage : external, internal  Fluid loss : vomiting,diarrhea,burns.

5. Haemorrhagic shock classification Class IClass IIClass IIIClass VI Volume loss (ml ) 0 - 750750 - 10001500 - 2000 ≥ 2000 Loss %0 - 1515 -3030 - 40 ≥ 40 Pulse beats / min < 100> 100> 120> 140 Blood pressure unchanged decreased Pulse pressureunchangeddecreased Urine output ml / h > 3020 - 305 -15anuric Respiratory rate / min 14 -2020 - 3030 -40> 40 Mental staterestlessAnxiousAnxious - confused confused Fluid replacement CrystalloidCrystalliod & colloid Colloid & blood

6. Cardiogenic shock  Cardiogenic shock  Inadequate blood flow to vital organs due to inadequate cardiac output despite normal blood volume.  Caused by : acute myocardial infarction,arrhythmia, myocarditis . 

7. Obstructive shock  Obstructive shock  Reduction of preload due to mechanical obstruction of cardiac contractility.  Caused by cardiac tamponade,tension pneumothorax, pulmonary embolism..

8. Distributive shock  Disrtributive shock  there is inadequate tissue perfusion accompanied by vascular dilatation,with hypotension and decrease peripheral vascular resistance.  Anaphylaxis : antigen antibody reaction → histamine release →  vasodilatation → ↓PVR..  High spinal cord injury : interruption of sympathetic outflow → VD.

9. Septic shock  Septic shock  Tissue hypoperfusion that occurs in the presence of systemic inflammatory response to infection.  Gram negative, gram positive bacteria.  Intraperitoneal abscess, genitourinary infections.central line infection.

10. hypovolemiccardiogenicobstructivedistributive Cardiac output ↓↓↓↑ Heart rate ↑↑↑↑ Blood pressure ↓↓↓↓ Peripheral vascular resistance ↑↑↑↓ Venous pressure ↓↑↑↓ Skin temperature ↓↓↓↑ acidosis √√√√

11.  Stages of shock  Compensated shock  Early, compensatory sympathetic stimulation  Altered level of consciousness,  Increased pulse rate  Increase respiratory rate  Pale clammy skin  Normal blood pressure

12.  Decompensated shock  late stage  Body looses ability to compensate  Rapid weak pulse  Shallow respiration  Extreme weakness  Pallor,cyanosis  Drop in blood pressure  oliguria

13.  Irreversible shock  Terminal stage  Organs suffer prolonged hypoxia  Return of function is irreversible despite aggressive adequate intervention  Unresponsiveness  Profound hypotension  Severe bradycardia  Apnea  Fixed dilated pupils

14. Presentation  Shock presents by  Altered mental status  Hypotension  Increased pulse rate  Increased respiratory rate  Oliguria  Cold pale skin,warm skin is seen in distributive shock  Manifestation of cause

15. Principles of management  General management principles 1.Golden hour. 2.Establish clear airway,adequate ventilation 3.Oxygen 4.Adequate intravenous access 5.Continuous cardiac monitoring 6.Urinary catheter 7.Record fluid balance 8.Maintain optimum temperature 9.Blood gases 10.Inotropes and vasoconstrictors may be used 11.Assess the response 12.Treat underlying cause.