1. 1.10

2. Management of Surgical Emergencies Part 1 : Critical Care
SHOCK
Copyright UKCS #

3. Learning Outcomes Define shock Understand the pathogenesis
Recognise shock
Principles of management
Understand the need for speedy resuscitation, finding the cause and calling for help.
Copyright UKCS #

4. Anaerobic metabolism and ultimately
What is Shock?
Circulatory collapse
leading to
Tissue hypoperfusion,
Cellular hypoxia,
Anaerobic metabolism and ultimately
Cell death
Copyright UKCS #

5. B
A — C — T
An important ETCC concept: ABC exist to support tissue oxygenation and organ function.

6. Recognising shock? Pulse? Blood Pressure? Capillary Refill?
Signs of poor organ perfusion:
Skin
Brain
Kidneys – reduced urine output
Gut
Metabolic acidosis
Central Venous Pressure?
Copyright UKCS #

7. Trauma Scenario 11 year old girl
Fell 6 ft from swing, face down on concrete. Immediate pain LUQ, but subsided; then pain left shoulder.
P 86/min, BP 150/90 mmHg; RR 18/min
O/E: Mild tenderness LUQ, no guarding.
Diagnosis?
Copyright UKCS #

8. 30 minutes later:Pulse 120/min; BP 140/80 mmHg
Ultrasound: free fluid in abdomen & pelvis; disruption of spleen architecture; ?tear.
To theatre from A&E for laparotomy.
Grade 3 Spleen Injury
Had a Splenorraphy
HAEMORRHAGIC SHOCK
Copyright UKCS #

9. Principles Tachycardia = earliest sign of shock (usually).
Any injured patient who is cool & tachycardic is in shock until proven otherwise.
Narrowed pulse pressure indicates significant blood loss.
Compensation can prevent systolic pressure drop (particularly in children)
Elderly patients can get early hypotension without tachycardia, and tolerate low BP poorly (beware B- blockers, pacemakers).
Copyright UKCS #

10. Types & Causes of Shock:
Hypovolaemic
Haemorrhagic – blood loss (6 compartments)
Non-haemorrhagic – burns, D&V, pancreatitis
Cardiogenic
Intrinsic – MI, LVD / LVF, Valve failure or stenosis, contusion
Obstructive – external compression of myocardium eg. Tamponade, tension pneumothorax, PPV
Distributive
Septic – loss of SVR, peripheral pooling & reduced venous return
Anaphylactic – mast cell breakdown, vasodiltation
Neurogenic – loss of autonomic control
Copyright UKCS #

11. CABCDE Management of shock Recognise the problem!
Copyright UKCS #

12. Management of shock Resuscitation
Reduce the flow, turn off the tap and replace some volume
What fluids?
What route?
When to give blood?
How much is enough?
Copyright UKCS #

13. Initial Fluid Therapy Normal Saline / Ringer’s Lactate (Hartmanns)
Adults: ml rapidly (profoundly shocked)
(Non-compressible, ongoing bleeding: avoid rapid fluid replacement. 250ml aliquots titrates to radial pulse and cerebration)
Rough guide: 300ml for every 100ml blood loss
Children: 10ml/kg initial dose + 10ml/Kg
Early consideration for blood
Copyright UKCS #

14. Monitor
Cerebration
Vital signs: Pulse (rate and quality), Cap refill, Blood pressure, Respiratory rate
Skin colour and temperature
Urine output
5. Haemodynamic parameters: CVP; Cardiac output, SvO2, Exp CO2, ph/H+
Copyright UKCS #

15. Response to resuscitation
Rapid Responder
Vital signs return to normal – no signs of ongoing blood loss
Time for further assessment & treatment
Transient Responder
Initial improvement, but deteriorated again
Suggests ongoing blood loss
Needs blood replacement
Early intervention
Non-responder
Urgently needs blood
Intervention necessary as part of resuscitation to turn off the tap
Copyright UKCS #

16. Scenario 2
16 year old boy
Admitted early evening with large volume fresh blood PR
Shocked – rapid response.
3 hours later: further bleeding; now needs blood
Further four episodes overnight
Consultant never informed!
5 units blood overnight
Consultant arrives on ward 07h45 during episode of bleeding; patient ashen faced, big silent eyes, extremities cold:
What was his immediate decision?
Copyright UKCS #

17. Turn off the tap! Immediately to theatre - Resuscitative surgery
Laparotomy: Bleeding Meckel’s diverticulum
Rapid full recovery
TRANSIENT RESPONDER – ongoing bleeding
Copyright UKCS #

18. Questions?

19. Summary Shock = Failure of tissue perfusion.
Obvious signs may appear late.
What is the cause?
Management principles are the same irrespective of the cause of shock.
Management:
Resuscitation
Treat Cause
Regular re-assessment
Manage secondary organ dysfunction due to hypoxia and acidosis
Copyright UKCS #