PTC shock Lt. col. Dr. Zaman Ranjha Associate prof. of Surgery

PTC Shock Objectives  To understand the structured approach to cerculatory problems  To recognize and manage shock

PTC Shock  Inadequate organ perfusion and tissue oxygenation  Most often due to hypovolaemia in surgery and trauma

PTC Shock Assessment Blood pressure Heart rate Capillary refill Peripheral temperature Peripheral colour Urine output

PTC Types of Shock  Hypovolaemic  Cardiogenic  Obstructive  Neurogenic  Endocrine  Anaphylactic  septic

PTC Severity of shock  Compensated Vasomotor response At the cost of skin, muscles and GIT. Acidosis beyond 12 Hrs- MOD  Decompensated 30-40% volume loss Cadiopulmonary and renal compensation is knocked out

PTC Shock Pathophysiology  Cellular Autodigestive enzyme-cell lysis  Microvascular o2 free radical- endothelial damage  Mode of death rapid-cadiopulmonary delayed-organ ischemia/reperfusion

PTC Hypovolumic shock  Fluid loss less intake, increased loss- vomiting, GIT, Renal third space- pancreatitis Blood loss

PTC Shock Sites of blood loss Closed Femoral #1.5-2 litres Closed Tibial # 500 ml Pelvic # 3 litres Rib # (each)150 ml Haemothorax 2 litres Hand sized wound 500 ml Fist sized clot500 ml

PTC Shock Concealed blood loss  Abdominal Cavity  Pleural Cavity  Femoral Shaft  Pelvic Fractures  Scalp (children)

PTC Types Of Bleeding  Compressible - usually peripheral  Non-compressible - e.g. intra-abdominal - Surgery required

PTC Shock systemic effects  CVS.-Sympathomymatic tachycardia-vasoconstriction Resp. -compensatory respiratory alkalosis Renal. Reduced perfusion, GFR, Urine Na, H2o, conservation Endocrine.Adrenal,cortisone =Na +water catecholamine Hypothalamus- vasopressin

PTC Shock Clinical Signs  Altered mental state : anxiety to coma  Pulse present ? - radial systolic > 80 mmHg - femoral systolic >70 mmHg - carotidsystolic > 60 mmHg  Tachycardia  Pulse pressure narrowed

PTC Shock Clinical Signs  Skin - cold, pale, sweaty, cyanosed  Capillary refill time > 2 seconds  Blood pressure  JVP  Urine output < 0.5 ml/kg/hr  Respiratory rate

PTC Clinical Signs In Shock

PTC Blood Loss < 750ml

PTC Blood Loss ml

PTC Blood Loss >1500ml

PTC Cardiogenic Shock  myocardial contusion  cardiac tamponade  tension pneumothorax  penetrating wound of heart  myocardial infarction  Valvular heart disease  arrhythmya

PTC Shock Obstructive shock  Cardiac temponade  Tension pneumothorax  Pulmonary embolism Reduced preload Reduced cardiac out put Engorged neck veins + oedma

PTC Shock Endocrine shock  May be combination of three  Adrenal- hypovolumic  Hypothyroid- neurogenic  Hyperthyroid – high out put

PTC Shock Distributive shock No volume depletion 1-Septic shock Endotoxin-vasodilation-AV shunting- cellular hypoxia 2- Anaphylactic shock Histamine- vasidilatation 3- Neurogenic- vasomotor

PTC Shock ?

PTC Shock Management  A + B, oxygen (if available)  Two large bore intra-venous cannulae  Stop obvious bleeding  Fluid replacement  Maintain temperature  Analgesia

PTC Shock Stop bleeding  Chest –Drain tube and re-expand lung –Emergency thoracotomy rarely  Abdomen –Laparotomy if hypotensive after fluids  Limbs –Pressure dressing –Tourniquet is last resort

PTC Shock Fluid replacement  Warm fluids if possible  Colloids or crystalloids?  Consider hypotensive resuscitation if haemostasis not secure- parallel with surgery  Consider oral resuscitation  Resuscitation beneficial –dehydration

PTC Shock Fluid replacement - How much? ml 0.9% Saline or Ringer’s Reassess ml 0.9% Saline or Ringer’s Reassess Consider blood Consider surgery Aim for systolic BP>90 + HR <100

PTC Shock Consider blood Tx  Haemodynamic instability in spite of fluids  Haemoglobin <7g/dl and patient still bleeding

PTC Shock ?

PTC Shock Summary  Careful assessment  Stop the bleeding  Replace volume  Correct the cause