Shock

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Shock
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What is Shock ? ? ?

• Shock is a failure of the circulatory system to
  maintain adequate perfusion of vital organs.
• cellular hypoxia
• anaerobic cellular metabolism
• accumulation of waste products in cells
• cellular death

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Types of Shock

• Distributive Shock
• Neurogenic shock
• Septic shock
• Anaphylactic shock
• Hypovolemic Shock
• Cardiogenic Shock

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Distributive Shock

• Distributive shock occurs as a result of
  inadequate vascular tone.
• neurogenic shock
• septic shock
• anaphylactic shock

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Hypovolemic Shock

• Hypovolemic shock occurs when there is a large
  reduction in the circulating blood volume.
• Actual hypovolemic shock - loss of blood or fluid
• Relative hypovolemic shock - internal fluid
  shifts from intravascular to interstitial space.

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Cardiogenic Shock

• Cardiogenic shock occurs when the heart is unable
  to function adequately resulting in insufficient
  blood flow to tissue and organs.
• myocardial infarction
• obstruction of blood flow
• congestive heart failure

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Stages of Shock

• Initial Stage
• Compensatory Stage
• Progressive Stage
• Irreversible Stage

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Stages of Shock

• Initial Stage
• Compensatory Stage
• Progressive Stage
• Irreversible Stage

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Initial Stage

• Initially, the body compensates with the onset of
  shock.
• No changes are noted clinically.
• Changes are beginning to occur on the cellular
  level.

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Stages of Shock

• Initial Stage
• Compensatory Stage
• Progressive Stage
• Irreversible Stage

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Compensatory Stage

• Fluid shift from insterstital to intravascular
  space.
• Activation of SNS - activation of epinephrine and
  norepinephrine.
• Kidneys release renin into blood formation
  of angiotension release of aldosterone, ADH

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Decreased CO
SNS stimulation
Renin secreted by kidney
hydrostatic pressure
Epinephrine norepinephrine released
Angiotension
fluid pulled into capillary
Aldosterone
Vasoconstriction
ADH
Increased SVR
Increase blood volume
Blood Pressure Maintained
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Stages of Shock

• Initial Stage
• Compensatory Stage
• Progressive Stage
• Irreversible Stage

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Progressive Stage

• Vicious circle of compensation eventually leads
  to decompensation.
• Blood pressure starts to fall - SBP below 80 is
  considered danger signal.
• Tachycardia tachypnea decreased urine output
  decreased body temperature cold, pale clammy
  skin.

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Stages of Shock

• Initial Stage
• Compensatory Stage
• Progressive Stage
• Irreversible Stage

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Irreversible Stage

• Body attempts at compensation have failed - death
  is imminent.
• Pooling and sludging of blood thrombosis of
  small vessels occurs.
• Tissue hypoxia and anoxia occur - lactic acid
  accumulation contributes to cell death.

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Management of Shock

• Treat underlying cause.
• Knowing the cause of the shock is necessary to
  treat the shock.

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Management of Shock

• Oxygenation
• In all types of shock, supplemental oxygen is
  administered to protect against hypoxemia.

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Management of Shock

• Positioning
• the recommended position for the patient in
  shock is supine with legs elevated 45 degrees.

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Management of Shock

• Replacing Fluid Volume
• The primary goal of shock therapy is to increase
  the circulating blood volume.
• crystalloids
• colloids
• Fluid replacement should be based on central
  venous pressures or pulmonary artery pressures
  and cardiac output.

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Management of Shock

• Pharmacologic Agents

• Vasoconstrictors
• Dopamine
• Norepinephrine
• Vasodilators
• Nitroprusside
• Nitroglycerin

• Sympathomimetics
• Epinephrine
• Corticosteriods
• Decadron
• Solumedrol
• Appropriate antidotes or antibiotics

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Complications of Shock

• Metabolic Acidosis
• Acute Tubular Necrosis
• DIC
• ARDS
• SIRS MOSF

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SIRS Multi-Organ System Failure

• May occur in patient who has survived a shock
  episode.
• Commonly associated with septic shock, especially
  gram negative septic shock

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Systemic Inflammatory Response Syndrome

• Causes damage to organs and tissues by
• damaging vascular endothelial cells
• hypermetabolism
• maldistribution of blood flow to organs
• organ hypoperfusion

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New Priorities in Septic Shock Care

• Multiple multi national research projects
• 4 new findings, care priorities
• 1. Use of activated protein C (Xigris)- new IV
  medication for septic shock
• expensive but effective
• 2. Use of high dose steroids
• test for reactiveness, then individualized dosing
• 3. Intensive insulin therapy
• tight glucose control (
• 4. Aggressive fluid therapy, monitoring

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Shock Recap

• Types of Shock
• Distributive Shock
• Neurogenic shock
• Septic shock
• Anaphylactic shock
• Hypovolemic Shock
• Cardiogenic Shock

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Recap

• Stages of Shock
• Initial Stage
• Compensatory Stage
• Progressive Stage
• Irreversible Stage

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Recap..

• Treatment of Shock
• O2,O2,O2, did I say oxygen?
• Positioning
• Fluids
• Colloids
• Crystalloids
• Pharmacological agents

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Cutting Edge Therapies

• Use of Xigris
• Use of steroids
• Intensive insulin therapy
• Aggressive fluid resuscitation/ monitoring