1. Shock

2. Shock : - Is inadequate organ perfusion - Is inadequate organ perfusion & tissue oxygenation & tissue oxygenation

3. Shock Classification : A. Hypovolemic A. Hypovolemic depletion of vasualar volium depletion of vasualar volium B. Cardiogenic B. Cardiogenic Intrinsic failure of the heart Intrinsic failure of the heart C. Neurogenic Shock C. Neurogenic Shock D. Septic D. Septic Severe untreated sepsis Severe untreated sepsis

4. Hypovolemic Shock. ( H.S ) Hypovolemic Shock. ( H.S )

5. Causese of H.S. : - Bleeding - Bleeding - Protracted vomiting or diarrhea - Protracted vomiting or diarrhea - Sequestration of fluid in gut lumen - Sequestration of fluid in gut lumen - Loss of plasma into injured tissues - Loss of plasma into injured tissues ( Burns / Trauma ) ( Burns / Trauma )

6. Compensatory mechanism Blood loss Blood loss Initial vasoconstriction of cutaneus Initial vasoconstriction of cutaneus - muscle – viscera - muscle – viscera Preserve blood flow for kidneys Preserve blood flow for kidneys - Heart - Brain - Heart - Brain

7. - Normal blood volume is about %7 of - Normal blood volume is about %7 of body weight body weight a 70 man # 5 Litre a 70 man # 5 Litre

8. Clinical manifestation of shock

9. Classification of (H.S.) :

10. Dx. Of Hypovolemic shock: Goal is : Restore adequate tissue perfusion. resuscitation is similar traumatized patient: - Stablishing Air way - Stablishing Air way - Stabilizing cervical spine - Stabilizing cervical spine - Dealing with ventilatory difficulties - Dealing with ventilatory difficulties - Managing circulatory problem - Managing circulatory problem - IV line – 16 G.cathater - IV line – 16 G.cathater

11. Dx of HVS: 1. Initial fluid resusitation : 1. Ringer`s lactate or 1. Ringer`s lactate or 2. Normal saline 2. Normal saline Disadvantages: Disadvantages: Hyperchloremic acidosis especially Impared renal function Hyperchloremic acidosis especially Impared renal function - Warming fluid for avoiding Hypothermia - Warming fluid for avoiding Hypothermia 1 – 2 L Immediately 1 – 2 L Immediately

12. Dx of HVS: Cont … 2.Crystaloids: 2.Crystaloids: Mixture of sodium chloride & other Physiologically active solutes Mixture of sodium chloride & other Physiologically active solutes - میزان سدیم مایع کریستالوئید تعیین کننده مقدار مایع معرفی خواهد بود. - سدیم عمدتا در Extra cellular Space و 80% Extra vascular است. - کریستالوئید ها سبب تجمع مایع در Interstitial Space می شود و در Vascular Space کمتر و حدود تقریبا 20% می باشد.

13. Dx of HVS : Cont … عوارض کریستالوئید ها : عوارض کریستالوئید ها : Hyperchloremic Metabolic acidosis Hyperchloremic Metabolic acidosis - Drug interaction due to - Drug interaction due to Calcium binding Ringer loctate Calcium binding Ringer loctate “ Balanced Electrolyte solution contain Na “ Balanced Electrolyte solution contain Na,Ca,K “,Ca,K “ Contraindication : Contraindication : - Dextrose – containing solution - Dextrose – containing solution ( ischemia to organ ) ( ischemia to organ )

14. Dx of HVS: Cont … 3. Colloids : 3. Colloids : ملکولهای بزرگ دارد و از دیواره عروق موئینه ملکولهای بزرگ دارد و از دیواره عروق موئینه نمی گذرد و ایجاد فشار اسمزی مثبت می کند و مایعات را نمی گذرد و ایجاد فشار اسمزی مثبت می کند و مایعات را بداخل عروق می کشاند. مصرف بالایی در شوکهای ناشی از هیپوولمی دارد - Human serum albumin - Human serum albumin - Hydroxyl ethyl starch - Hydroxyl ethyl starch - Dextrans - Dextrans

15. Dx of HVS: Cont … 3-1. Albumin : 3-1. Albumin : - %80 of osmotic plasma pressure - %80 of osmotic plasma pressure - Carrier protein of Ca, Mg. - Carrier protein of Ca, Mg. - Available : - Available : %5 ( 50 g/l ) or %25 (250 g/l ) %5 ( 50 g/l ) or %25 (250 g/l ) in isotonic saline in isotonic saline - Increase 5 time intravascular volume - Increase 5 time intravascular volume - Disadv : - Disadv : Allergic reaction Allergic reaction - Half life 36 Hs - Half life 36 Hs

16. Dx of HVS: Cont … 3-2. Hetastarch : 3-2. Hetastarch : - Synthetic Starch %6 ( 60 g/l ) - Synthetic Starch %6 ( 60 g/l ) in isotonic solution in isotonic solution - Half life 24 / H - Half life 24 / H - Disadvantage : - Disadvantage : - Hyper Amylasemia - Hyper Amylasemia - Allergy - Allergy

17. Dx of HVS: Cont … 3-3. Dextran – 40 3-3. Dextran – 40 - Polysaccharide Sugar beet - Polysaccharide Sugar beet - Expand intravascular volume twice - Expand intravascular volume twice - Half life 6 Hs - Half life 6 Hs - Dis adv : - Dis adv : - Bleeding risk inhibition of platelet aggregation - Bleeding risk inhibition of platelet aggregation - Anaphylaxia - Anaphylaxia - Interference with crossmatching - Interference with crossmatching - Acute renal failure Hypoosmolar state - Acute renal failure Hypoosmolar state

18. Dx of HVS: Cont … 4 - Hypertonic Saline : 4 - Hypertonic Saline : %7.5 NaCl or ( 750 g/l ) %7.5 NaCl or ( 750 g/l ) Infusion Rate : Infusion Rate : 4 mL / Kg / 2 minutes 4 mL / Kg / 2 minutes Maintain pressure 1 - 2 Hs Maintain pressure 1 - 2 Hs Amount : Amount : 250 mL infusion 250 mL infusion Dis adv : Dis adv : - uncontrol Hemorrhage - uncontrol Hemorrhage - Systemic acidosis - Systemic acidosis

19. Dx of HVS: Cont … 5 – Blood Component therapy ( BCT ) 5 – Blood Component therapy ( BCT ) - Fully crossmatched blood - Fully crossmatched blood time 1 hour time 1 hour Specific or saline crossmatched Specific or saline crossmatched time 10 minutes time 10 minutes - ABO grouping - Rh - ABO grouping - Rh - Whole blood - Whole blood Bag ( 450 ml ) with 50 ml Anticoagulant Bag ( 450 ml ) with 50 ml Anticoagulant preservative (citrate, dextrose, phosphate ) preservative (citrate, dextrose, phosphate ) - Stored 1 – 6 ̊c - Stored 1 – 6 ̊c

20. Dx of HVS: Cont … 5 – Blood component therapy 5 – Blood component therapy - Shelf life of whole blood 21 days - Shelf life of whole blood 21 days - Packed cells - Packed cells - Blood warmer / pressurized - Blood warmer / pressurized infusion ( 200 mmHg – 2 to 3 times ) infusion ( 200 mmHg – 2 to 3 times ) - Use wide – bore catheter - Use wide – bore catheter Note Warming blood reduces it viscosity

21. Dx of HVS: Cont … 6 – Ultimate goal of Dx : 6 – Ultimate goal of Dx : - Normal blood pressure - Normal blood pressure Heart rate Heart rate Urine output Urine output

22. The End