Shock

SHOCK

• clinical syndrome that develops when oxygen delivery is inadequate to meet the metabolic requirement of the tissue due to some form of acute circulatory failure

• five broad categories
  • Hypovolaemic shock : due to conditions causing major reduction in blood volume
    • internal or external hemorrhage, severe burns, dehydration, ketoacidosis
  • Cardiogenic shock : due to conditions causing any form of heart failure
    • MI, cardiac contusion
  • Obstructive shock : due to conditions causing any form of obstruction to circulation
    • pulmonary embolism, cardiac tamponade
  • Anaphylactic shock : allergens triggering vasodilatation
  • Septic shock : severe infection or inflammation causing capillary leak or inappropriate vasodilatation
• 
  

Hypovolaemic shock

• most common cause of shock in trauma patient
• leads to
  • hemostasis of circulation
  • decrease in ventilation
  • decrease in metabolic functions
• Clinical features
  • sweating
  • unconsciousness, confusion, decreased responsiveness, irritability
  • tachypnoea
  • hypotension <100mm Hg
  • tachycardia with low volume pulse >100/min
  • cold cyanosed peripheries
  • poor urine output <30ml/hr
• Treatment
  • resuscitation – crystalloid solution – large bore I/v line- RL solution
  • monitor with urine output – goal of 0.5mL/kg/hr in adults
  • also CVP, pulmonary artery pressure
  • severe degree of shock – venous constriction – I/v cut down of saphenous or cubital veins needed
• Classes

Classes of Shock
	I	II	III	IV
Blood loss (L)	<750	750 -1500	1.5 - 2	>2 l
Blood volume loss %	<15%	15 -30	30 -40	>40%
Pulse rate	<100	>100	>120	>140
Urine output (ml/hr)	>30	20-30	5-15	negligible

• Blood infusion combined with crystalloid infusion at a ration of 3:1 is recommended
• RBC concentrate if massive bleeding suspected
• identify the bleeding source when volume restoration have been started
  • Chest, pelvis, cervical spine, head radiographs
  • USG pelvis
• treat component deficiencies if needed – thrombocytopenia if levels go below 50,000/ul – FFP if hypofibrinogemia, factor V and VIII
• large volume infusion – leads to hypothermia – coagulation dysfunction – warming of patients
• Complications
  • inadequate tissue perfusion – cellular dysoxia – multiple organ failure
    • intra cerebral bleeding – confusion , coma
    • ARDS
    • myocardial depression
    • liver failure with hyperbilirubinaemia
    • GIT mucosal damage, bleeding into GIT, ileus
    • skin hemorrhage, infarct
    • gangrene

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