Blok : Trauma and Emergency SHOCK

dr. Imam Ghozali., M.Kes, Sp.An

Departemen Ilmu Anestesi Fakultas Kedokteran Universitas Malahayati Bandar Lampung

What is Shock?
Inadequate perfusion of body tissue that begins at the cellular level and if left untreated results in death of tissue, organs, organ systems, and ultimately the entire organism IT IS NOT LOW BLOOD PRESSURE!

Shock is a result of many reasons:

Trauma Fluid loss MI Infection Allergic Reaction Spinal Cord Injury Other reasons

What is adequate perfusion?

Constant and necessary passage of blood through the bodys tissue

Perfusion is dependent on a functioning and intact circulatory system

Components of circulatory system

The pump(heart) The fluid(blood) The container(blood vessels)

The Pump
The Heart is the pump of the cardiovascular system It receives blood from the venous system then pumps the blood to the lungs for oxygenation, then to the peripheral tissues

Stroke Volume
The amount of blood ejected by the heart in one contraction

Factors affecting stroke volume

Preload Cardiac Contractile Force Afterload

Preload
Amount of blood delivered to the heart during diastole

Cardiac Contractile Force

The strength of contraction of the heart It is affected by circulating hormones called catecholamines -Epinepherine -NorEpinepherine

Frank Starling Mechanism

The greater the stretch of the cardiac muscle, up to a certain point, the greater the force of cardiac contraction(I.E. the rubber band effect)

Afterload
Resistance against which the ventricle must contract Determined by the degree of peripheral vascular resistance

Cardiac Output
Amount of blood pumped in one contraction Stroke volume x Heart rate=Cardiac output

Peripheral Vascular Resistance

Pressure against which the heart must pump Blood pressure=cardiac output x peripheral vascular resistance

Fluid
Blood is thicker and more adhesive than water Consist of plasma and formed elements: Red cells, White cells, Platelets Transports oxygen, carbon dioxide, nutrients, hormones, and metabolic waste An adequate amount is needed for perfusion

Container
Blood vessels serve as the container Under control of the autonomic nervous system they can adjust size and selectively reroute blood through microcirculation Microcirculation is comprised of the small vessels: Arterioles, Capillaries, and Venules

Container cont
Capillaries have a sphincter between the arteriole and capillary called the pre-capillary sphincter Pre-capillary sphincter responds to local tissue demands such as acidosis, hypoxia, and opens as more blood is needed

Post-Capillary Sphincter
At the end of the capillary between the capillary and venule Opens when blood is needed to be emptied into the venous system

Blood Flow Regulation

Peripheral Vascular Resistance Pressure within the system

Major functions of Perfusion

Oxygen transport Waste Removal

Inadequate Pump
Inadequate preload Inadequate cardiac contractile strength Inadequate heart rate Excessive afterload

Inadequate Fluid
Hypovolemia (abnormally low circulating blood volume)

Inadequate Container
Dilated container without change in fluid volume Leak in container

Shock at cellular level

The causes of shock vary, however the ultimate outcome is impairment of cellular metabolism

Impaired use of oxygen

When cells dont receive enough oxygen or cannot use it effectively, they change from aerobic to anaerobic metabolism

Glucose breakdown. (A) Stage one, glycolysis, is anaerobic (does not require oxygen). It yields pyruvic acid, with toxic by-products such as lactic acid, and very little energy. (B) Stage two is aerobic (requires oxygen). In a process called the Krebs or citric acid cycle, pyruvic acid is degraded into carbon dioxide and water, which produces a much higher yield of energy.

Compensated and Decompensated shock

Usually the body is able to compensate but when these mechanisms fail shock develops and may progress

Compensation Mechanisms
Catecholamines may be secreted ( I.E. Epinephrine and norepinephrine) The Renin-Angitensin system aids in maintaining blood pressure Endocrine Response by pituitary gland results in secretion of anti-diuretic hormone (ADH)

Catecholamine Release
Epinephrine and Norepinephrine release affects the cardiovascular system, causing increase in HR, increase in Cardiac contractility strength, arteriolar constriction which elevates blood pressure

Renin-Angiotensin system
Renin is released from the kidneys and acts on specialized plasma protein called Angiotensin the produces AngiotensinI. AngiotensinI is converted to AngiotensinII by enzymes in the lungs called Angiotensin Converting Enzyme (ACE)

Renin-Angiotensin System (cont)

AngiotensinII is a potent vasoconstrictor Angiotensin II stimulates production of aldostrone, which causes the kidneys to reabsorb sodium

Anti-Diuretic Hormone
Causes the kidneys to reabsorb water creating an additive to the aldostrone

Compensated Shock
Early stages of shock where the bodys compensatory mechanisms are able to maintain normal perfusion

Decompensated Shock
Advanced stage of shock that occurs when the bodys compensatory mechanisms fail to maintain normal perfusion

Irreversible Shock
Stage of shock that has progressed to the point that the body nor medical interventions correct the problem

Types of shock
Cardiogenic shock (Inadequate Pump) Hypovolemic shock (Inadequate Fluid) Neurogenic shock (Inadequate Container) Anaphylactic shock Septic shock

Cardiogenic Shock
The heart loses the ability to supply all body parts with blood Usually the result of left ventricular failure secondary to acute MI or CHF Many patients will have normal blood pressures

S/S of Cardiogenic Shock

Major difference between other types of shock is presence of Pulmonary Edema Difficulty breathing Wheezes, Crackles, Rales are heard as fluid levels increase Productive cough with white or pink-tinged foamy sputum Cyanosis Altered mentation Oliguria ( decreased urination)

TX for Cardiogenic Shock

Assure open airway Adminster oxygen Assist ventilations as needed Keep patient warm Place patient in position of comfort Establish Iv with minimal fluid administration Monitor Vitals May need to administer Dopamine or Dobutamine

Hypovolemic Shock
Internal or external hemorrhage Trauma Long bone or open FXs Dehydration Plasma loss due to burns Excessive sweating Diabetic Ketoacidosis with resultant osmotic diuresis

S/S of Hypovolemic Shock

Pale, cool, clammy skin Blood pressure may be normal then fall Pulse may be normal then become rapid, finally slowing and disappearing Urination decreases Cardiac dysrhythmias may occur

Tx for Hypovolemic Shock

Airway control Administer high flow oxygen Control severe bleeding Keep patient warm Elevate lower extremities Establish IV and administer bolus of crystalloid solution for fluid replacement

Neurogenic Shock
Results from injury to brain or spinal cord causing interruption of nerve impulses to arteries Arteries lose tone and dilate causing hypovolemia Sympathetic nerve impulses to the adrenal glands are lost, which prevents the release of catecholamines and their compensatory effects

Neurogenic Shock (cont)

High cervical injuries cause interruption of impulse to peripheral nervous system causing Neurogenic shock is most commonly due to severe injury to spinal cord or total transection of cord (spinal shock)

S/S of Neurogenic Shock

Warm, Dry, Red Skin Low Blood Pressure Slow Pulse

TX for Neurogenic Shock

Airway control Maintain body temperature Immobilization if indicated Consider other causes of shock IV and medications that increase peripheral vascular resistance (I.E. Norepinephrine, Dopamine)

Anaphylatic Shock
Severe immune response to foreign substance S/S most often occur within minutes but can take up to hours to occur The faster the reaction develops the more severe it is likely to be Death will occur if not treated promptly

S/S of Anaphylactic Shock

Skin - Flushing - Itching - Hives -Swelling -Cyanosis

S/S of Anaphylactic Shock

Respiratory System - Breathing difficulty - Sneezing, Coughing - Wheezing, Stridor - Laryngeal edema - Laryngospasm

S/S of Anaphylactic Shock

Cardiovascular System - Vasodilation - Increased heart rate - Decreased blood pressure

S/S of Anaphylactic Shock

Gastrointestinal System - Nausea, vomiting - Abdominal cramping - Diarrhea

TX for Anaphylactic Shock

Airway protection which may include Endotracheal Intubation Establish IV with crystalloid solution Pharmacological interventions: Epinephrine, Antihistamines(Benadryl), Corticosteroids(dexamethasone), Vasopressors(dopamine, Epinephrine), and inhaled beta agonist(albuterol)

Septic Shock
An infection enters bloodstream and is carried throughout body Toxins released overcome compensatory mechanisms Can cause dysfunction of one organ system or cause multiple organ dysfunction

S/S of Septic Shock

Increased to low blood pressure High fever, no fever, hypothermic Skin flushed, Pale, Cyanotic Difficulty breathing and altered lung sounds Altered LOC

TX of Septic Shock
Airway control Administer oxygen IV of crystalloid solution Dopamine for blood pressure support Monitor other vitals

Multiple Organ Dysfunction Syndrome

MODS is the progressive impairment of two or more systems from and uncontrolled inflammatory response to a severe illness or injury

Progression To MODS
Infection Sepsis Septic shock MODS Death(if not corrected early)

Primary MODS
Organ damage due to specific cause such as ischemia or inadequate tissue perfusion from shock, trauma, or major surgery Stress and inflammatory responses may be mild or undetected During the response, neutrophils, macrophages, and mast cells are thought to be primed by cytokines

Secondary MODS
The next time there is injury, ischemia, or infection the primed cells are activated, producing and exaggerated inflammatory response The inflammatory response enters a selfperpetuating cycle causing damage and vasodilation And exaggerated neuroendocrine response is triggered causing futher damage

24 hours post resuscitation

Low grade fever Tachycardia Dyspnea Altered mental status

Within 24 to 72 hours
Pulmonary failure begins

Within 7 to 10 days
Hepatic failure begins Intestinal failure begins Renal failure begins

Within 14 to 21 days
Renal and Hepatic failure intensify Gastrointestinal collapse Immune system collapse

After 21 days
Hematologic failure begins Myocardial failure begins Altered Mental status resulting from Encephalopathy Death