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General Surgery Orientation Medical Student Lecture Series
Shock General Surgery Orientation Medical Student Lecture Series Dr. Peter Meade
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SHOCK
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SHOCK Burning building Desert
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SHOCK Low perfusion Low Oxygen Delivery Cells deprived of Oxygen Glucose incompletely metabolized Lactic Acidosis
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Burning glucose without Oxygen = lactic acidosis Burning wet sticks = smoke
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Krebs Cycle 36 ATPs Anaerobic glycolysis 2 ATPs
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Hypoperfusion Anaerobic glycolysis Lactic Acidemia
Low bicarbonate Low pH Multisystem Organ Failure
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SHOCK Lack of Oxygen Delivery Low blood pressure Cell Damage
Decreased perfusion of tissues with Oxygen Cell Damage Inflammatory Response
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Lack of Oxygen Delivery Inflammatory Response
SHOCK Lack of Oxygen Delivery (Hypoperfusion) i Cellular Damage Inflammatory Response Hypoperfusion causes Inflammation Inflammation causes Hypoperfusion
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What causes…. SHOCK
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SHOCK Hypovolemic Obstructive Cardiogenic Distributive
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SHOCK Hypovolemic -Hemorrhagic Obstructive Cardiogenic Distributive
-Non-hemorrhagic dehydration, burns, GI losses, pancreatitis Obstructive Cardiogenic Distributive
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SHOCK HYPOVOLEMIC hemorrhagic
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Lack of Oxygen Delivery
SHOCK Lack of Oxygen Delivery (Hypoperfusion) h Hypovolemia Bleeding / Hemorrhage Hypoperfusion causes Inflammation Inflammation causes Hypoperfusion
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SHOCK HYPOVOLEMIC Non-hemorrhagic fluid losses
Open wounds Burns- incredible fluid losses !
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Treat the primary cause
TREATMENT OF SHOCK Treat the primary cause “Source Control” Hemorrhagic / Hypovolemic Stop the bleeding Replace blood loss, volume
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Starling Curve Preload Contractility Afterload
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Starling Curve Preload Contractility Afterload
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Hypovolemic Shock Hemorrhagic shock (3 categories) 1. Compensated:
0-20% of blood loss Blood pressure is maintained increased vascular tone increased blood flow to vital organs
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Hypovolemic Shock The body’s response:
Compensated shock Baroreceptor mediated vasoconstriction Increased epinephrine, vasopressin, angiotensin Results in: Tachycardia Tachypnea Lowered pulse pressure Slightly lowered urine output
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Hypovolemic Shock 2. Uncompensated: 20-40% loss of blood volume
Decrease in BP Tachycardia
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Hypovolemic Shock 3. Lethal exsanguination: 40% loss of blood volume
Profound hypotension and inability to perfuse vital organs
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Hypovolemic Shock Volume Resuscitation ~ What are my goals?
1. Rapid Responder Give 500cc-1 Liter crystalloid rapid improvement of BP/HR/Urine output < 20% blood loss Surgery consult
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Hypovolemic Shock Volume Resuscitation ~ What are my goals?
2.Transient Responder 500cc-1 Liter crystalloid improves briefly then deteriorates 20-40% blood loss Continue crystalloid infusion +/- Blood Surgery consult
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Hypovolemic Shock Volume Resuscitation ~ What are my goals?
3. Non Responder Give 2 Liters crystalloid/ 2 units Blood no response > 40% blood loss STAT Surgery consult!
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Hypovolemic Shock Is my volume resuscitation adequate/inadequate?
Urine output Vital signs Skin perfusion Pulse Oximetry Acidemia
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Hypovolemic Shock Loss of circulating blood volume (Plasma)
Normal Blood Volume: - 7% IBW in adults - 9% IBW in children
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SHOCK Hypovolemic Obstructive Cardiogenic Distributive
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SHOCK Hypovolemic Obstructive Cardiogenic Distributive
poor diastolic filling: -tension pneumothorax -pericardial tamponade -abdominal compartment syndrome poor systolic contraction: -pulmonary embolus -aortic dissection, tumors Cardiogenic Distributive
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SHOCK Obstructive decreased venous return
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SHOCK Hypovolemic Obstructive Cardiogenic Distributive
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SHOCK CARDIOGENIC Pump Failure Cardiogenic Shock
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SHOCK Hypovolemic Obstructive Cardiogenic Distributive
Myocardial infarction, contusion, myocarditis Mechanical valve failure, VSD, ventricular wall defects Distributive
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Lack of Oxygen Delivery
SHOCK Lack of Oxygen Delivery (Hypoperfusion) h Cardiogenic Acute Myocardial infarction Aortic or mitral valve dysfunction Dysrhythmia Cardiac contusion Massive Pulmonary embolism Cardiac Tamponade Congestive Heart Failure Hypoperfusion causes Inflammation Inflammation causes Hypoperfusion
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Cardiogenic Shock Acute hypotension low cardiac output
inadequate LV outflow Poor end organ perfusion!
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SHOCK Hypovolemic Obstructive Cardiogenic Distributive
Septic, anaphylactic, neurogenic, pharmacologic, endocrinologic
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SHOCK: SEPTIC: Endotoxins from bacteria = Shock!
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Lack of Oxygen Delivery
SHOCK Lack of Oxygen Delivery (Hypoperfusion) h Septic Septicemia, Endotoxins, Vasodilatation, pneumonia, urinary tract infection, dead intestine, necrotic tissue Hypoperfusion causes Inflammation Inflammation causes Hypoperfusion
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Septic Shock exaggerated endogenous inflammatory response to invasive infection leading to: -circulatory collapse -multiple organ failure -death
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Septic Shock Mortality over 35% (sepsis with hypotension)
45% (sustained septic shock)
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Treat the primary cause
TREATMENT OF SHOCK Treat the primary cause “Source Control” Septic Drain the abscess Treat with antibiotics, volume, pressor agents
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Lack of Oxygen Delivery Inflammatory Response
SHOCK Lack of Oxygen Delivery (Hypoperfusion) i Cellular Damage Inflammatory Response Hypoperfusion causes Inflammation Inflammation causes Hypoperfusion
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The Inflammatory Response It can be like using a machine gun to kill a fly on the wall…. You might get the fly, but the wall gets hit too!
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Inflammatory Response
Vasoconstriction Vasodilation Capillary leak Nitric Oxide, PG2, kinins, histamine serotonin White Cells/ Polymorphonuclear cells Phagocytosis: proteases, Interleukins
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Inflammatory Response
Platelet Activation PDGF TGF-B WBC Products P-seletin E-selectin ICAM 1 WBC Proteases IL-1, IL8 TNF
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