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Shock
Objectives
Identify
CASE STUDY
A 25
V/S
Temp:
Questions
Shock
Or
:Pathophysiology
1- Inadequate tissue perfusion and oxygenation
2- Compensatory responses
3- The specific etiology --- you should manage
the patient but must aim to treat the underlying
cause.
Classification
1- Hypovolemic: (hemorrhagic (internal as bleeding ulcers or external as acute blood
loss), non-hemorrhagic ( dehydration as vomiting and diarrhea,3rd fluid spacing as in
burns and pancreatitis).
2- Cardiogenic: pump related, any type of cardiomyopathies (ischemic, myopathy,
mechanical,
arrhythmogenic either braycardic or tachycardia).
3- Distributive: mainly due to vasodilation (septic, adrenal crises due to steroids
withdrawal mostly iatrogenic, neurogenic loss of sympathetic tone when there is trauma
to the thoracic or lumbar sympathetic chain or spinal cord injury, anaphylactic as in
hypersensitivity reactions if severe form).
4- Obstructive: (massive PE, tension pneumothorax(space is obstructed by fluid),
cardiac tamponade( space is obstructed with blood, constrictive pericarditis(space
is obstructed due to the inflammation.)
*spinal shock is different from neurogenic , its just motor loss which is transient and due to
concussion, no vascular changes so not considered as an ER shock
CT of pulmonary embolism
Hypovolemic Shock
When
1- Hemorrhage.
2- GI loss
3- Urinary loss
4- Dehydration
Hypovolemic Shock
Management
Distributive shock
It
The
Hemodynamic Profile
Cardiac
output
normal or increased
Ventricular filing pressure normal or low
SVR
low
Diastolic pressure low
Pulse pressure
wide
Cardiogenic Shock
Forward
:Hemodynamic Profile
Cardiac
output
Low
SVR
High
High
Obstructive Shock
Obstruction to the outflow due to impaired cardiac
filling and excessive after-load
Cardiac tamponade & constrictive pericarditis impair
diastolic filling of the Rt. ventricle
Tension pneumothorax obstructs venous return
limiting Rt. ventricular filing.
* In tension pneumothorax there is positive gradient
pressure limiting venous return
Massive pulmonary embolism increase the Rt.
ventricular after-load.
Hemodynamic Profile
Cardiac
output
low
Afterload * same as SVR (systemic venous return )
high
Lt.Vent.filling pressure
variable
Pulsus paradoxicus
(in Tamponade)
* Pulsus paradoxicus normally with inspiration it
increase by 10 beats if more then positive for
temponade .
Distended Jugular veins
General Principles
The overall goal of shock management is to improve oxygen
delivery or utilization in order to prevent cellular and organ
injury.
* Defect in utilization as in CO poising because hemoglobin has
higher affinity to CO and even if one oxygen went there the CO
will prevent the off-load and if it did at the mitochondrial level it
wil block the respiratory chain .
1- Monitoring.
2- Fluid Therapy.
3- Vasoactive agents.
4- Treat the underlying cause.
THANK YOU