8cdfmanagement of Shock

7/28/2019 8cdfmanagement of Shock

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MANAGEMENT OF

SHOCK

- GARGYA


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SHOCK....syndrome resulting from inadequate perfusion oftissues.

Aim of management.restoration of perfusion of the tissues. Restoration would be complete only after knowing the cause

for shock

Etiology is established by taking history, clinical features, lab

investigations, radiographic studies and other tests.

Once the cause is known, the approach of treatment varies

based on the type of shock.

HYPOVOLEMIC

CARDIOGENIC

SEPTIC NEUROGENIC

TRAUMATIC

HYPOADRENAL

ANAPHYLACTIC


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The most fundamental emergency management of anycase would be the ABCs.i.e.

Airway.maintaining a patent airway, may be withendotracheal intubation

Breathingproper ventilation of lungs, may be withassistance

Circulationmaintaining the blood circulation, which in thiscontext mainly means maintenance of blood

volume and also prevention of pooling of blood.

The main TARGETof management of shock is Mean arterial pressure at 60-80 mm of Hg

Maximize the oxygen delivery


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HYPOVOLEMIC ......!!!

Diagnosis Hemodynamic instability. Obvious source of volume loss.(u/s scan for abd.aneurysm, endoscopy for

GI bleed, X-Ray, pregnancy test for ectopic pregnancy, etc.)

Lab investigations CBC, electrolytes, PT, aPTT, ABGs, urine analysis,blood grouping and cross matching.

Treatment At a prehospital level

prevent further loss, immobilize, ensure ventilation, and immediatetransport to a hospital

At the emergency dept.

assess airway and stabilize it, asses the RR and breath sounds High flow supplementary oxygen to all and assisted ventilation to theneeded

Obtain IV access, start fluid resuscitation with an isotonic crystalloid(RL, NS), 1-3 lit in 30 mins

If hemodynamic stability doesnt restore with crystalloids transfuseblood


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Identify the source of bleeding and control bleedingDirect pressure for external bleeding.

Surgical intervention for internal bleeding.

Various other concepts in controlling bleeding are Vasopressin and H2 blockers for GI bleed.

Traction in case of long bone fracture.

Surgery in case of all Gync. bleeds.

If hypovolemia is severe or prolonged IONOTROPICSare to be used to maintain ventricular performance afterblood volume is restored.

As an adjunct the TREDELENBURGs position is to be

maintained ( elevating the legs alone is the optimalposition..transient effectdelays recovery if prolonged.) Thisis mainly useful to regain consciousness after a syncopalepisode.


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Cardiogenic shock......!!!

Two types are the Intrinsic

Compressive

There would be no absolute or relative hypovolemia in this case.

Diagnosis of intrinsic type

H/O heart disease, Hemodynamic changes, ECG, Xray, Echocardiogram, Sr.cardiac markers

Target is to increase the CO without changing the HR

Treatment of intrinsic type

Airway patency and oxygenation

Mech. Ventilation in max cases Fluid resuscitation (in the absence of pulm. edema)

Central venous and arterial access, bladder catheterisation, pulse oximetryare routine.

PAC (pulm. artery catheter ) needed for hemodynamic monitoring.

Electrolyte abnormalities should be corrected


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INOTROPES

The most important drugs in cardiogenic shock are the Inotropes i.e.Dopamine, Dobutamine, Nor epinephrine, Vasopressin.

Dopamine, nor epinephrine and vasopressin act by bothvasoconstrictors and inotropes

Dobutamnie is used only when arterial pressure is restored as it is ainotrope but a vasodilator.

OTHER DRUGS

Furosemide is used in the presence of pulm. Congestion

Morphine for anxiolysis

IABP Intra Aortic Baloon Pumping, is done if the patient fails tostabilise with the above treatment. The balloon is inflated during the early

diastole to augment the coronary blood flow and hence helps recovery ofmyocardium

Finally surgical interventions like revascularisation should be done basingon the etiology.


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Diagnosis of compressive type

H/O, clinical features, chest radiography, echocardiogram.

Classical C/F in case of cardiac tamponade are hypotension,neck vein dilatation, muffled heart sounds.

Treatment of compressive type

Specific treatment in tamponade cases is immediatepericardiocentesis

Chest decompression

Release of air or other contents in cases like pneumothoraxetc.


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Septic shock......!!!

There are two types Hyperdynamic

Hypodynamic

Clinical features

Hyperdynamic tachycardia, norm. or increased CO, decreased systmc vascularresistance and increased pulm. Resistance (oxygen delivery is good but extraction isbad)

Hypodynamic vasoconstriction and decreased CO, inc. PR, febrile, cold n mottledcyanotic extremities, oliguria, renal failure, inc. Sr.lactate.

Diagnosis

By the C/F, leucocytosis or leucopoenia, thrombocytopenia.

Definitive diag. by the isolation and identification of microbes and detection ofendotoxin in blood


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Treatment

Antimicrobials initial therapy with brd spectrum

antibiotics and later based on the culture reports specificdrug is to be given.

Removal of source of infection like sites of occult infns,iv catheters, Foleys n drainage catheters etc.

Rule out other causes of sep[sis using X-ray, CT, U/S.

Hemodynamic support

- IV fluids 1-2 lit of NS over 2hrs

- Urine output maintained at >0.5 ml/kg/hr

- Diuretic is used when needed.- If fluid resuscitation fails, inotropics and vasopressors

are used.

Respiratory support by mechanical ventilation . If Hb

8cdfmanagement of Shock

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