1. In the name of GOD Hypotention/shock Reza ghaderi DR 1393-spring

2.  Definition  Shock is a physiologic state characterized by a significant reduction of systemic tissue perfusion, resulting in decreased oxygen delivery to the tissues.  This creates an imbalance between oxygen delivery and axygen consumption.

3.  Tissue perfusion = cardiac out put * sys vascular resistance  C.O = heart rate * stroke volume  Stroke volume depend on preload, afterload, myocardial contractility  S.V.R depend on vascular length, vascular diameter, after load

4.  Type of shock;   Hypovolemic  Cardiogenic  Distributive

5.  Hypovolemic; decreased preload due to intravascular volume loss that resulting decreased cardiac output and P.C.W.P and increased S.V.R.ni  Cardiogenic; decreased cardiac contractility; pump failure; decreased C.O and increased S.V.R and P.C.W.P  Distributive; consequence of severely decreased S.V.R.  C.O increased for compensation and P.C.W.P may nl or low

6.  Shock stages;  Pre shock; reduction of 10% intra vascular volume  Warmness, increased heart rate, peripheral vasoconstriction  Shock; reduction of 25% intra vascular volume  Tachycardia, tachypnea, agitation, met acidosis, oligouria, sweating, cold skin  End organ damage; decreased C.O

7.  Clinical manifestation  Hypotention ;that present in all type of shock  Sys BP<90 or more than 40mmHg reduction in base  Decrease level of conciseness ; agitation to coma  Oliguria; due to blood shifting toward principal organs  Cool and clammy skin; due to blood shifting to vital organs  Metabolic acidosis; due to decreased clearance of lactate in liver, kidney, skeletal muscle. 

8.  Associated finding;  Hematemesis, hematochesia, melena, vomiting, diarrhea, abd pain, trauma, post operation state  P/E;  Dry skin  Dry axilla  Decreased skin turgor  Decreased Hb  Decreased J.V.P  Increased amylase and lipase

9.  Cardiogenic shock; chest pain, dyspnea, palpitation, C.V.D Hx, crackle, mur mur, gallop, increased JVP, ECG, cardiac marker,  Distributive shock; dysuria, productive cough, dyspnea, hematuria, rash, fatigue, pain, tachypnea, tachycardia, increased W.B.C, photophobia

10.  DDX;  Hypovolemic shock categorized to two group  Hemorhagic shock: trauma, gi bleeding, rupture of hematoma, hemorrhagic pancratitis, FX, rupture of aneurism,  Loss of volume; diarrhea, vomiting, heat, burn, small intestine obstruction, pancratitis, cirrhosis,

11.  Cardiogenic shock categorized to four groups;  Myopathic; dilated cardiomyopathy, MI>40% LV surface, RVMi, multi vessel disease  Arrhythmia ; AF, Flutter, V.T, bradyarrhythmia, C.H.B  Mechanical; valvular, mixom, V.S.D  Obstructive; extra cardiac; P.T.E, C.P, tamponad, severe PAP

12.  Distributive;  Septic shock, T.S.S, SIRS, anaphylaxis, drugs, toxin, bites, transfusion, adrenal crisis, post CPR

13.  Approach;  HX  P/E  Labs  Mortality; 35-60% in septic shock  60-90% in cardiogenic shock  variable in hypovolemic shock

14.  Management ;  Hypovolemic; rate of resuscitation  choice of fluid Cardiogenic distributive

15.  Good luck