1. SHOCK

2. Objectives Understand what shock is Understand what shock is Define types of shock Define types of shock Understand Pathophysiology of shock Understand Pathophysiology of shock Understand how to treat shock Understand how to treat shock

3. WHAT IS SHOCK? Inadequate Tissue Perfusion

4. Symptoms of Shock Anxiety /Nervousness Anxiety /Nervousness Dizziness Dizziness Weakness Weakness Faintness Faintness Nausea & Vomiting Nausea & Vomiting Thirst Thirst Confusion Confusion Decreased UO Decreased UO Hx of Trauma / other illness Hx of Trauma / other illness Vomiting & Diarrhoea Vomiting & Diarrhoea Chest Pain Chest Pain Fevers / Rigors Fevers / Rigors SOB SOB General SymptomsSpecific Symptoms

5. Signs of Shock Pale Cold & Clammy Sweating Cyanosis Tachycardia Tachypnoea Confused / Aggiatated Unconscious Hypotensive Stridor / SOB

6. Circulatory Homeostasis BP = CO X PVR CO – Cardiac Output PVR – Peripheral Vascular resistance Tissue perfusion is driven by blood pressure

7. Cardiac Output CO = SV X HR This means that BP= SV X HR X PVR Blood Pressure = Stroke Volume X Heart Rate X Peripheral Vascular Resistance

8. Stroke Volume Volume of Blood pumped by the heart during 1 cycle Volume of Blood pumped by the heart during 1 cycle What affects Stroke volume? Heart Muscle Damage Blood Volume Mechanical Obstruction Rhythm Problems

9. What makes up blood volume Plasma RBCs WBCs Platelets

10. What Alters Blood Volume? Haemorrhage Haemorrhage Plasma Loss Plasma Loss Redistribution of Extracellular Volume Redistribution of Extracellular Volume

11. Heart Rate Heart rate increases as a compensatory response to Shock Heart rate increases as a compensatory response to Shock Rarely you get Rarely you get High Output failure Heart rate too fast to allow adequate refilling of heart between beats

12. Peripheral Vascular Resistance PVR regulated by ARTERIOLAR tone. Dilatation opens Arteriovenous beds & increases volume of circulatory system

13. What Alters PVR? Circulation cytokines & Inflammatory mediators (e.g. Histamine) Circulation cytokines & Inflammatory mediators (e.g. Histamine) Endotoxins Endotoxins Drugs (e.g. Nitrates) Drugs (e.g. Nitrates)

15. Types of Shock HypovolaemicCardiogenicRedistributive

16. Hypovolaemic Volume Loss Volume Loss Blood loss -Haemorrhage Blood loss -Haemorrhage Plasma Loss-Burns / Pancreatitis

17. Cardiogenic Pump Failure Pump Failure May be due to inability of heart to Contact inability of heart to Contact Inability of heart to pump blood Inability of heart to pump blood

18. Redistributive Decreased Peripheral Vascular Resistance Decreased Peripheral Vascular Resistance Septic Shock Septic Shock Spinal / Neurogenic Shock Spinal / Neurogenic Shock ANAPHYLACTIC shock ANAPHYLACTIC shock

19. Pathophysiological Response “Flight or fight response” “Flight or fight response” Increased Catecholamine release Increased Catecholamine release Activation of Renin-Angiotensin system Activation of Renin-Angiotensin system Increase glucocorticoid and mineralcorticoid release Increase glucocorticoid and mineralcorticoid release Activation of Sympathetic nervous system Activation of Sympathetic nervous system

20. Treatment of Shock ABCABC

21. Ensure Adequate Intravascular Volume Ensure Adequate Intravascular Volume Support Pump Support Pump

22. Anaphylactic Shock Caused by a hypersensitivity reaction to an allergen in a previously sensitised patient Caused by a hypersensitivity reaction to an allergen in a previously sensitised patient

23. Common Allergens Nuts Bee / Wasp Stings DRUGS

24. Common Features Angio-oedema Angio-oedema Bronchoconstriction Bronchoconstriction Vasodilatation and hypotension Vasodilatation and hypotension Urticareal rash Urticareal rash

25. Angio-oedema

26. Treatment RECOGNISE THE PROBLEM GET HELP ABC

27. Treatment Ensure Airway is adequate Ensure Airway is adequate Oxygen Oxygen IV access early IV access early IV fluids IV fluids ADRENALINE 0.5ml 1 in 1000 IM ADRENALINE 0.5ml 1 in 1000 IM Bronchodilators Bronchodilators Steroids Steroids

28. SHOCK Clinical Scenarios

29. 1) A 26 year old man with a comminuted closed fracture of the femur shaft undergoes intramedullary nail fixation. Two days post operatively, he develops a pyrexia, shortness of breath and tachycardia. 1) A 26 year old man with a comminuted closed fracture of the femur shaft undergoes intramedullary nail fixation. Two days post operatively, he develops a pyrexia, shortness of breath and tachycardia. Discuss the emergency management? Discuss the emergency management?

30. 2) A 72 year old man develops sudden back pain and is brought to the emergency department with a swollen,tense abdomen. He is tachycardic,with a low volume pulse and low BP. 2) A 72 year old man develops sudden back pain and is brought to the emergency department with a swollen,tense abdomen. He is tachycardic,with a low volume pulse and low BP. Discuss the emergency management? Discuss the emergency management?

31. 3) A 72 year old man with an underlying prostate carcinoma sustains a femoral shaft fracture.He undergoes intramedullary nail fixation. At post operative day 7 he develops a shortness of breath,hypotension and a tachycardia 3) A 72 year old man with an underlying prostate carcinoma sustains a femoral shaft fracture.He undergoes intramedullary nail fixation. At post operative day 7 he develops a shortness of breath,hypotension and a tachycardia Discuss the emergency management? Discuss the emergency management?