1. PTC shock Lt. col. Dr. Zaman Ranjha Associate prof. of Surgery

2. PTC Shock Objectives  To understand the structured approach to cerculatory problems  To recognize and manage shock

3. PTC Shock  Inadequate organ perfusion and tissue oxygenation  Most often due to hypovolaemia in surgery and trauma

4. PTC Shock Assessment Blood pressure Heart rate Capillary refill Peripheral temperature Peripheral colour Urine output

5. PTC Types of Shock  Hypovolaemic  Cardiogenic  Obstructive  Neurogenic  Endocrine  Anaphylactic  septic

6. PTC Severity of shock  Compensated Vasomotor response At the cost of skin, muscles and GIT. Acidosis beyond 12 Hrs- MOD  Decompensated 30-40% volume loss Cadiopulmonary and renal compensation is knocked out

7. PTC Shock Pathophysiology  Cellular Autodigestive enzyme-cell lysis  Microvascular o2 free radical- endothelial damage  Mode of death rapid-cadiopulmonary delayed-organ ischemia/reperfusion

8. PTC Hypovolumic shock  Fluid loss less intake, increased loss- vomiting, GIT, Renal third space- pancreatitis Blood loss

9. PTC Shock Sites of blood loss Closed Femoral #1.5-2 litres Closed Tibial # 500 ml Pelvic # 3 litres Rib # (each)150 ml Haemothorax 2 litres Hand sized wound 500 ml Fist sized clot500 ml

10. PTC Shock Concealed blood loss  Abdominal Cavity  Pleural Cavity  Femoral Shaft  Pelvic Fractures  Scalp (children)

11. PTC Types Of Bleeding  Compressible - usually peripheral  Non-compressible - e.g. intra-abdominal - Surgery required

12. PTC Shock systemic effects  CVS.-Sympathomymatic tachycardia-vasoconstriction Resp. -compensatory respiratory alkalosis Renal. Reduced perfusion, GFR, Urine Na, H2o, conservation Endocrine.Adrenal,cortisone =Na +water catecholamine Hypothalamus- vasopressin

13. PTC Shock Clinical Signs  Altered mental state : anxiety to coma  Pulse present ? - radial systolic > 80 mmHg - femoral systolic >70 mmHg - carotidsystolic > 60 mmHg  Tachycardia  Pulse pressure narrowed

14. PTC Shock Clinical Signs  Skin - cold, pale, sweaty, cyanosed  Capillary refill time > 2 seconds  Blood pressure  JVP  Urine output < 0.5 ml/kg/hr  Respiratory rate

15. PTC Clinical Signs In Shock

16. PTC Blood Loss < 750ml

17. PTC Blood Loss 750-1500ml

18. PTC Blood Loss >1500ml

19. PTC Cardiogenic Shock  myocardial contusion  cardiac tamponade  tension pneumothorax  penetrating wound of heart  myocardial infarction  Valvular heart disease  arrhythmya

20. PTC Shock Obstructive shock  Cardiac temponade  Tension pneumothorax  Pulmonary embolism Reduced preload Reduced cardiac out put Engorged neck veins + oedma

21. PTC Shock Endocrine shock  May be combination of three  Adrenal- hypovolumic  Hypothyroid- neurogenic  Hyperthyroid – high out put

22. PTC Shock Distributive shock No volume depletion 1-Septic shock Endotoxin-vasodilation-AV shunting- cellular hypoxia 2- Anaphylactic shock Histamine- vasidilatation 3- Neurogenic- vasomotor

23. PTC Shock ?

24. PTC Shock Management  A + B, oxygen (if available)  Two large bore intra-venous cannulae  Stop obvious bleeding  Fluid replacement  Maintain temperature  Analgesia

25. PTC Shock Stop bleeding  Chest –Drain tube and re-expand lung –Emergency thoracotomy rarely  Abdomen –Laparotomy if hypotensive after fluids  Limbs –Pressure dressing –Tourniquet is last resort

26. PTC Shock Fluid replacement  Warm fluids if possible  Colloids or crystalloids?  Consider hypotensive resuscitation if haemostasis not secure- parallel with surgery  Consider oral resuscitation  Resuscitation beneficial –dehydration

27. PTC Shock Fluid replacement - How much? 1000-2000ml 0.9% Saline or Ringer’s Reassess 1000-2000ml 0.9% Saline or Ringer’s Reassess Consider blood Consider surgery Aim for systolic BP>90 + HR <100

28. PTC Shock Consider blood Tx  Haemodynamic instability in spite of fluids  Haemoglobin <7g/dl and patient still bleeding

29. PTC Shock ?

30. PTC Shock Summary  Careful assessment  Stop the bleeding  Replace volume  Correct the cause